- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.60 / $723.60 / $723.60
| Facility | | $723.60 | $723.60 | $723.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.53 / $723.60 / $723.60
| Professional | | $652.53 | $723.60 | $723.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.51 / $2,262.46 / $3,954.16
| Professional | | $1,478.51 | $2,262.46 | $3,954.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,128.04 / $5,873.73 / $6,056.46
| Facility | | $4,128.04 | $5,873.73 | $6,056.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.73 / $1,489.62 / $1,489.62
| Professional | | $679.73 | $1,489.62 | $1,489.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.95 / $640.67 / $1,994.43
| Professional | | $394.95 | $640.67 | $1,994.43 |