- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.77 / $584.77 / $584.77
| Facility | | $584.77 | $584.77 | $584.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.77 / $724.36 / $724.36
| Professional | | $584.77 | $724.36 | $724.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $890.16 / $890.16 / $890.16
| Facility | | $890.16 | $890.16 | $890.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.75 / $999.12 / $3,730.92
| Professional | | $618.75 | $999.12 | $3,730.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.20 / $729.60 / $1,679.86
| Professional | | $463.20 | $729.60 | $1,679.86 |