- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $937.65 / $937.65 / $987.66
| Facility | | $937.65 | $937.65 | $987.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.28 / $950.15 / $1,182.51
| Professional | | $725.28 | $950.15 | $1,182.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.70 / $1,181.72 / $1,418.07
| Professional | | $938.70 | $1,181.72 | $1,418.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $93.11 / $109.54
| Professional | | $93.11 | $93.11 | $109.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $100.00 / $2,074.00
| Facility | | $64.00 | $100.00 | $2,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.91 / $74.86 / $837.60
| Professional | | $49.91 | $74.86 | $837.60 |