- 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 / $550.00 / $636.39
| Professional | | $517.29 | $550.00 | $636.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.24 / $925.65 / $1,075.50
| Facility | | $874.24 | $925.65 | $1,075.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $300.25 / $300.25
| Professional | | $300.25 | $300.25 | $300.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $250.00 / $250.00
| Professional | | $250.00 | $250.00 | $250.00 |