- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $433.28 / $450.00 / $450.00
| Facility | | $433.28 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Professional | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.73 / $371.73 / $371.73
| Professional | | $371.73 | $371.73 | $371.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.30 / $500.30 / $500.30
| Professional | | $500.30 | $500.30 | $500.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.19 / $626.08 / $1,057.80
| Professional | | $465.19 | $626.08 | $1,057.80 |