- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $588.62
| Facility | | $588.62 | $588.62 | $588.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $588.62
| Professional | | $588.62 | $588.62 | $588.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.25 / $1,160.25 / $1,160.25
| Professional | | $1,160.25 | $1,160.25 | $1,160.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.00 / $1,491.00 / $1,491.00
| Professional | | $1,491.00 | $1,491.00 | $1,491.00 |