- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.00 / $1,383.20 / $1,520.00
| Facility | | $760.00 | $1,383.20 | $1,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.40 / $1,383.20 / $1,520.00
| Professional | | $600.40 | $1,383.20 | $1,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.50 / $325.50 / $325.50
| Facility | | $325.50 | $325.50 | $325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.50 / $325.50 / $325.50
| Professional | | $325.50 | $325.50 | $325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $456.00 / $1,140.00
| Professional | | $319.20 | $456.00 | $1,140.00 |