- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.92 / $352.92 / $1,101.10
| Facility | | $352.92 | $352.92 | $1,101.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.92 / $352.92 / $352.92
| Professional | | $352.92 | $352.92 | $352.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.84 / $374.98 / $374.98
| Professional | | $8.84 | $374.98 | $374.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.92 / $441.15 / $982.00
| Facility | | $352.92 | $441.15 | $982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.92 / $389.69 / $467.62
| Professional | | $352.92 | $389.69 | $467.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.63 / $367.63 / $390.02
| Professional | | $367.63 | $367.63 | $390.02 |