- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.35 / $123.35 / $123.35
| Facility | | $123.35 | $123.35 | $123.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Professional | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.00 / $1,695.00 / $1,695.00
| Professional | | $1,695.00 | $1,695.00 | $1,695.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.52 / $258.52 / $258.52
| Professional | | $258.52 | $258.52 | $258.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.00 / $2,797.00 / $3,372.00
| Professional | | $2,164.00 | $2,797.00 | $3,372.00 |