- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $575.28
| Facility | | $575.28 | $575.28 | $575.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $750.00
| Professional | | $575.28 | $575.28 | $750.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.92 / $1,413.90 / $1,499.73
| Facility | | $1,295.92 | $1,413.90 | $1,499.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.42 / $1,403.42 / $1,403.42
| Professional | | $1,403.42 | $1,403.42 | $1,403.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $759.90
| Facility | | $575.28 | $575.28 | $759.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $750.00 / $1,074.18
| Professional | | $750.00 | $750.00 | $1,074.18 |