- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $561.60 / $3,414.53
| Facility | | $504.00 | $561.60 | $3,414.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.60 / $561.60 / $626.40
| Professional | | $561.60 | $561.60 | $626.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.00 / $756.00 / $993.60
| Professional | | $720.00 | $756.00 | $993.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.53 / $1,773.72 / $4,105.30
| Facility | | $1,308.53 | $1,773.72 | $4,105.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $561.60 / $720.00 / $909.79
| Facility | | $561.60 | $720.00 | $909.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.39 / $410.67 / $720.00
| Professional | | $302.39 | $410.67 | $720.00 |