- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $517.29
| Facility | | $517.29 | $517.29 | $517.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $605.00
| Professional | | $517.29 | $517.29 | $605.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.78 / $331.55 / $607.04
| Facility | | $107.78 | $331.55 | $607.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.33 / $334.16 / $334.16
| Professional | | $267.33 | $334.16 | $334.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.94 / $550.00 / $874.24
| Facility | | $443.94 | $550.00 | $874.24 |