- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.59 / $801.77 / $1,675.75
| Facility | | $609.59 | $801.77 | $1,675.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.00 / $183.00 / $228.75
| Professional | | $183.00 | $183.00 | $228.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.62 / $578.78 / $578.78
| Facility | | $146.62 | $578.78 | $578.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.31 / $133.31 / $133.31
| Facility | | $133.31 | $133.31 | $133.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.31 / $133.31 / $133.31
| Professional | | $133.31 | $133.31 | $133.31 |