- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $585.04
| Facility | | $585.04 | $585.04 | $585.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $603.50
| Professional | | $585.04 | $585.04 | $603.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $39.94
| Professional | | $30.00 | $30.00 | $39.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.66 / $539.66 / $1,052.33
| Professional | | $539.66 | $539.66 | $1,052.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.87 / $603.87 / $603.87
| Facility | | $603.87 | $603.87 | $603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.73 / $1,000.73 / $1,000.73
| Professional | | $1,000.73 | $1,000.73 | $1,000.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $602.59 / $988.72
| Facility | | $585.04 | $602.59 | $988.72 |