- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $2,466.84
| Facility | | $836.47 | $836.47 | $2,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $343.54
| Professional | | $343.54 | $343.54 | $343.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.92 / $624.92 / $624.92
| Professional | | $624.92 | $624.92 | $624.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |