- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.31 / $330.31 / $330.31
| Facility | | $330.31 | $330.31 | $330.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $502.88 / $507.49
| Professional | | $461.36 | $502.88 | $507.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.80 / $1,668.00 / $1,668.00
| Professional | | $1,417.80 | $1,668.00 | $1,668.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.24 / $435.24 / $435.24
| Facility | | $435.24 | $435.24 | $435.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $652.86 / $652.86
| Professional | | $461.36 | $652.86 | $652.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |