- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,288.25
| Professional | | $630.96 | $870.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $1,445.44
| Facility | | $1,380.38 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $758.58 / $1,513.56
| Professional | | $575.44 | $758.58 | $1,513.56 |