- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.18 / $390.18 / $390.18
| Facility | | $390.18 | $390.18 | $390.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.08 / $390.18 / $390.18
| Professional | | $84.08 | $390.18 | $390.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.24 / $785.24 / $785.24
| Professional | | $785.24 | $785.24 | $785.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.81 / $261.81 / $1,294.79
| Professional | | $261.81 | $261.81 | $1,294.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $2,331.75
| Professional | | $1,438.66 | $1,438.66 | $2,331.75 |