- 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
- $760.00 / $760.00 / $760.00
| Facility | | $760.00 | $760.00 | $760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.00 / $760.00 / $760.00
| Professional | | $760.00 | $760.00 | $760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $456.00 / $1,297.30
| Professional | | $319.20 | $456.00 | $1,297.30 |