- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.48 / $390.48 / $1,682.45
| Facility | | $390.48 | $390.48 | $1,682.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $390.48
| Professional | | $327.43 | $327.43 | $390.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $347.08 / $419.11
| Facility | | $327.43 | $347.08 | $419.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |