- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.46 / $661.00 / $1,006.75
| Facility | | $508.46 | $661.00 | $1,006.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.08 / $508.46 / $508.46
| Professional | | $490.08 | $508.46 | $508.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.00 / $2,705.65 / $2,705.65
| Facility | | $600.00 | $2,705.65 | $2,705.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $520.71
| Professional | | $510.50 | $510.50 | $520.71 |