- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.58 / $487.58 / $487.58
| Facility | | $487.58 | $487.58 | $487.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.58 / $487.58 / $487.58
| Professional | | $487.58 | $487.58 | $487.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.00 / $1,170.00 / $1,275.30
| Professional | | $1,170.00 | $1,170.00 | $1,275.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.83 / $1,397.92 / $1,597.62
| Facility | | $1,261.83 | $1,397.92 | $1,597.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $640.00 / $1,475.00
| Professional | | $182.55 | $640.00 | $1,475.00 |