- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $549.54 / $660.69
| Professional | | $524.81 | $549.54 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,000.00
| Facility | | $562.34 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $2,818.38
| Professional | | $562.34 | $562.34 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $549.54 / $660.69
| Professional | | $537.03 | $549.54 | $660.69 |