- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.54 / $648.54 / $648.54
| Facility | | $648.54 | $648.54 | $648.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $569.84
| Professional | | $65.00 | $65.00 | $569.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.55 / $1,670.55 / $1,749.27
| Professional | | $1,670.55 | $1,670.55 | $1,749.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.79 / $648.54 / $664.05
| Professional | | $352.79 | $648.54 | $664.05 |