- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.80 / $759.80 / $1,563.28
| Facility | | $759.80 | $759.80 | $1,563.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.80 / $1,046.84 / $1,620.00
| Professional | | $759.80 | $1,046.84 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.33 / $146.75 / $172.22
| Professional | | $138.33 | $146.75 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.87 / $662.87 / $973.12
| Professional | | $662.87 | $662.87 | $973.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.80 / $785.65 / $1,291.66
| Facility | | $759.80 | $785.65 | $1,291.66 |