- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.61 / $790.61 / $988.26
| Facility | | $790.61 | $790.61 | $988.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $988.26 / $990.00
| Professional | | $900.00 | $988.26 | $990.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $736.38 / $920.47
| Professional | | $736.38 | $736.38 | $920.47 |