- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.00 / $520.00 / $520.00
| Facility | | $520.00 | $520.00 | $520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.76 / $520.00 / $520.00
| Professional | | $513.76 | $520.00 | $520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.00 / $806.00 / $1,664.00
| Professional | | $650.00 | $806.00 | $1,664.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.77 / $845.77 / $1,118.10
| Professional | | $845.77 | $845.77 | $1,118.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.40 / $218.40 / $520.00
| Professional | | $218.40 | $218.40 | $520.00 |