- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.63 / $437.33 / $517.29
| Facility | | $388.63 | $437.33 | $517.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $605.00
| Professional | | $517.29 | $517.29 | $605.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.76 / $600.00 / $600.00
| Professional | | $49.76 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.29 / $198.02 / $289.45
| Facility | | $124.29 | $198.02 | $289.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $643.50
| Facility | | $517.29 | $517.29 | $643.50 |