- 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
- $45.60 / $49.76 / $60.00
| Professional | | $45.60 | $49.76 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $765.21
| Facility | | $588.62 | $588.62 | $765.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |