- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.51 / $496.74 / $496.74
| Facility | | $496.51 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $854.00
| Professional | | $496.74 | $496.74 | $854.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.28 / $496.74 / $496.74
| Professional | | $481.28 | $496.74 | $496.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Facility | | $496.74 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Professional | | $496.74 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Professional | | $496.74 | $496.74 | $496.74 |