- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $662.32 / $662.32 / $1,407.43
| Facility | | $662.32 | $662.32 | $1,407.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.48 / $536.48 / $536.48
| Professional | | $536.48 | $536.48 | $536.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.39 / $2,000.00 / $2,000.00
| Professional | | $397.39 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.32 / $662.32 / $668.94
| Professional | | $662.32 | $662.32 | $668.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $662.32 / $662.32 / $1,072.96
| Facility | | $662.32 | $662.32 | $1,072.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.48 / $536.48 / $662.32
| Professional | | $536.48 | $536.48 | $662.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.78 / $397.39 / $1,159.06
| Professional | | $337.78 | $397.39 | $1,159.06 |