- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.04 / $532.04 / $532.04
| Facility | | $532.04 | $532.04 | $532.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.04 / $532.04 / $532.04
| Professional | | $532.04 | $532.04 | $532.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.05 / $1,171.05 / $1,328.39
| Professional | | $1,171.05 | $1,171.05 | $1,328.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $93.39 / $93.39
| Professional | | $93.39 | $93.39 | $93.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.98 / $96.95 / $170.27
| Professional | | $60.98 | $96.95 | $170.27 |