- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $527.87
| Facility | | $527.87 | $527.87 | $527.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.53 / $527.87 / $527.87
| Professional | | $521.53 | $527.87 | $527.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.84 / $818.00 / $1,689.00
| Professional | | $659.84 | $818.00 | $1,689.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.86 / $1,055.86 / $1,055.86
| Facility | | $1,055.86 | $1,055.86 | $1,055.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.55 / $858.55 / $1,135.18
| Professional | | $858.55 | $858.55 | $1,135.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.71 / $221.71 / $527.87
| Professional | | $221.71 | $221.71 | $527.87 |