- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $531.16
| Facility | | $450.00 | $450.00 | $531.16 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $991.08 / $1,095.25 / $2,088.75
| Facility | | $991.08 | $1,095.25 | $2,088.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.32 / $464.77 / $1,054.03
| Professional | | $380.32 | $464.77 | $1,054.03 |