- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.02 / $524.02 / $524.02
| Facility | | $524.02 | $524.02 | $524.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.25 / $529.26 / $635.11
| Professional | | $529.25 | $529.26 | $635.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.02 / $524.02 / $529.26
| Professional | | $524.02 | $524.02 | $529.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $674.06
| Professional | | $529.26 | $529.26 | $674.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $1,242.00
| Professional | | $529.26 | $529.26 | $1,242.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $561.02
| Professional | | $529.26 | $529.26 | $561.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.38 / $526.38 / $526.38
| Professional | | $526.38 | $526.38 | $526.38 |