- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $679.91
| Facility | | $519.54 | $519.54 | $679.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $519.54 / $519.54
| Professional | | $360.00 | $519.54 | $519.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $665.68 / $948.89 / $2,329.33
| Facility | | $665.68 | $948.89 | $2,329.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $136.81 / $730.00
| Professional | | $109.45 | $136.81 | $730.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.26 / $633.26 / $633.26
| Facility | | $633.26 | $633.26 | $633.26 |