- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.35 / $734.35 / $734.35
| Facility | | $734.35 | $734.35 | $734.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.35 / $819.78 / $958.64
| Professional | | $734.35 | $819.78 | $958.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.77 / $1,525.62 / $1,672.66
| Professional | | $1,296.77 | $1,525.62 | $1,672.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.52 / $1,440.19 / $2,294.62
| Professional | | $768.52 | $1,440.19 | $2,294.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.35 / $1,032.09 / $1,441.64
| Facility | | $734.35 | $1,032.09 | $1,441.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.16 / $799.26 / $5,352.44
| Professional | | $517.16 | $799.26 | $5,352.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.68 / $770.79 / $1,124.47
| Professional | | $473.68 | $770.79 | $1,124.47 |