- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.73 / $323.73 / $1,303.82
| Facility | | $323.73 | $323.73 | $1,303.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.73 / $323.73 / $323.73
| Professional | | $323.73 | $323.73 | $323.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.00 / $424.00 / $540.71
| Professional | | $424.00 | $424.00 | $540.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.80 / $360.80 / $360.80
| Professional | | $360.80 | $360.80 | $360.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.14 / $514.14 / $1,570.14
| Professional | | $514.14 | $514.14 | $1,570.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.08 / $394.61 / $738.73
| Professional | | $263.08 | $394.61 | $738.73 |