- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.83 / $585.83 / $585.83
| Facility | | $585.83 | $585.83 | $585.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.47 / $593.64 / $859.56
| Professional | | $476.47 | $593.64 | $859.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.53 / $738.36 / $886.03
| Professional | | $586.53 | $738.36 | $886.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.70 / $768.75 / $1,233.75
| Professional | | $75.70 | $768.75 | $1,233.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.39 / $4,948.92 / $5,129.34
| Facility | | $1,010.39 | $4,948.92 | $5,129.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.26 / $401.93 / $608.25
| Professional | | $278.26 | $401.93 | $608.25 |