- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.44 / $413.44 / $422.57
| Facility | | $413.44 | $413.44 | $422.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.44 / $413.44 / $426.85
| Professional | | $413.44 | $413.44 | $426.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.00 / $1,568.00 / $1,568.00
| Professional | | $874.00 | $1,568.00 | $1,568.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.14 / $550.61 / $1,094.53
| Professional | | $550.14 | $550.61 | $1,094.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.86 / $729.60 / $1,316.55
| Professional | | $479.86 | $729.60 | $1,316.55 |