- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $585.04
| Facility | | $585.04 | $585.04 | $585.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $1,000.00
| Professional | | $585.04 | $585.04 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,940.71 / $3,034.83 / $4,722.57
| Facility | | $1,940.71 | $3,034.83 | $4,722.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $719.60
| Facility | | $585.04 | $585.04 | $719.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.62 / $1,385.62 / $1,385.62
| Professional | | $1,385.62 | $1,385.62 | $1,385.62 |