- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.00 / $1,316.46 / $1,421.18
| Facility | | $299.00 | $1,316.46 | $1,421.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.69 / $321.26 / $345.06
| Professional | | $313.69 | $321.26 | $345.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.50 / $331.25 / $331.25
| Professional | | $187.50 | $331.25 | $331.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.76 / $730.76 / $730.76
| Professional | | $730.76 | $730.76 | $730.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.17 / $359.05 / $359.05
| Professional | | $342.17 | $359.05 | $359.05 |