- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.08 / $414.08 / $414.08
| Facility | | $414.08 | $414.08 | $414.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.01 / $414.08 / $438.37
| Professional | | $362.01 | $414.08 | $438.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.33 / $505.66 / $1,486.07
| Professional | | $367.33 | $505.66 | $1,486.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.72 / $467.91 / $958.36
| Professional | | $397.72 | $467.91 | $958.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.44 / $367.84 / $1,036.65
| Professional | | $297.44 | $367.84 | $1,036.65 |