- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $649.44
| Facility | | $519.54 | $519.54 | $649.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $450.67 / $519.54
| Professional | | $360.00 | $450.67 | $519.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.04 / $435.04 / $435.04
| Facility | | $435.04 | $435.04 | $435.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $109.45 / $136.81
| Professional | | $109.45 | $109.45 | $136.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.04 / $519.54 / $519.54
| Facility | | $435.04 | $519.54 | $519.54 |