- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.48 / $361.48 / $361.48
| Facility | | $361.48 | $361.48 | $361.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.48 / $361.48 / $361.48
| Professional | | $361.48 | $361.48 | $361.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.00 / $474.00 / $603.76
| Professional | | $474.00 | $474.00 | $603.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.77 / $382.77 / $382.77
| Professional | | $382.77 | $382.77 | $382.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.09 / $574.09 / $1,753.22
| Professional | | $574.09 | $574.09 | $1,753.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.75 / $440.62 / $824.87
| Professional | | $293.75 | $440.62 | $824.87 |