- 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 / $1,646.03
| Professional | | $588.62 | $588.62 | $1,646.03 |
- 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
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $1,646.03 / $1,646.03
| Facility | | $588.62 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |