- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $519.54
| Facility | | $519.54 | $519.54 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $519.54
| Professional | | $519.54 | $519.54 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.50 / $661.50 / $661.50
| Professional | | $661.50 | $661.50 | $661.50 |
- 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
- $109.45 / $136.81 / $470.00
| Professional | | $109.45 | $136.81 | $470.00 |