- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.71 / $935.37 / $1,115.35
| Facility | | $394.71 | $935.37 | $1,115.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.71 / $394.71 / $530.12
| Professional | | $394.71 | $394.71 | $530.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.70 / $586.70 / $659.25
| Professional | | $586.70 | $586.70 | $659.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.62 / $402.62 / $402.62
| Professional | | $402.62 | $402.62 | $402.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.85 / $626.85 / $1,914.38
| Professional | | $626.85 | $626.85 | $1,914.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.75 / $481.12 / $722.89
| Professional | | $320.75 | $481.12 | $722.89 |