- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.75 / $477.75 / $477.75
| Facility | | $477.75 | $477.75 | $477.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $477.75 / $495.02
| Professional | | $460.48 | $477.75 | $495.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Professional | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $591.63 / $646.67
| Professional | | $30.00 | $591.63 | $646.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.47 / $790.67 / $1,135.11
| Facility | | $571.47 | $790.67 | $1,135.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.60 / $575.60 / $575.60
| Professional | | $575.60 | $575.60 | $575.60 |