- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.28 / $518.28 / $518.28
| Facility | | $518.28 | $518.28 | $518.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.54 / $440.54 / $440.54
| Professional | | $440.54 | $440.54 | $440.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.85 / $803.00 / $1,658.00
| Professional | | $647.85 | $803.00 | $1,658.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,036.33 / $1,036.33
| Facility | | $1,036.33 | $1,036.33 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.62 / $843.11 / $1,152.25
| Professional | | $252.62 | $843.11 | $1,152.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.68 / $217.68 / $518.28
| Professional | | $217.68 | $217.68 | $518.28 |