- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $688.07 / $688.07 / $786.36
| Facility | | $688.07 | $688.07 | $786.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $688.07 / $786.36
| Professional | | $655.29 | $688.07 | $786.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $655.29
| Facility | | $655.29 | $655.29 | $655.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $655.29
| Professional | | $655.29 | $655.29 | $655.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.54 / $655.29 / $851.89
| Professional | | $622.54 | $655.29 | $851.89 |