- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.52 / $477.52 / $477.52
| Facility | | $477.52 | $477.52 | $477.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.52 / $520.27 / $610.48
| Professional | | $477.52 | $520.27 | $610.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.22 / $1,194.36 / $1,309.49
| Professional | | $1,015.22 | $1,194.36 | $1,309.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.40 / $1,036.49 / $1,670.63
| Professional | | $490.40 | $1,036.49 | $1,670.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.52 / $729.02 / $1,021.66
| Facility | | $477.52 | $729.02 | $1,021.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.88 / $812.44 / $3,786.99
| Professional | | $476.88 | $812.44 | $3,786.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.27 / $683.10 / $1,035.43
| Professional | | $462.27 | $683.10 | $1,035.43 |