- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.38 / $455.76 / $455.76
| Facility | | $376.38 | $455.76 | $455.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.38 / $376.38 / $376.38
| Professional | | $376.38 | $376.38 | $376.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.22 / $394.22 / $394.22
| Professional | | $394.22 | $394.22 | $394.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.16 / $427.16 / $427.16
| Professional | | $427.16 | $427.16 | $427.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.98 / $458.98 / $1,401.71
| Professional | | $458.98 | $458.98 | $1,401.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.86 / $352.29 / $499.08
| Professional | | $234.86 | $352.29 | $499.08 |