- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.94 / $524.94 / $524.94
| Facility | | $524.94 | $524.94 | $524.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.94 / $524.94 / $524.94
| Professional | | $524.94 | $524.94 | $524.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.90 / $1,078.90 / $1,078.90
| Professional | | $1,078.90 | $1,078.90 | $1,078.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.79 / $526.79 / $1,874.76
| Professional | | $526.79 | $526.79 | $1,874.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.52 / $624.76 / $748.36
| Professional | | $373.52 | $624.76 | $748.36 |