- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.62 / $896.62 / $896.62
| Facility | | $896.62 | $896.62 | $896.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.62 / $896.62 / $896.62
| Professional | | $896.62 | $896.62 | $896.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.91 / $1,041.91 / $1,041.91
| Professional | | $1,041.91 | $1,041.91 | $1,041.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.87 / $735.87 / $1,452.24
| Professional | | $735.87 | $735.87 | $1,452.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.39 / $1,592.13 / $1,788.91
| Professional | | $311.39 | $1,592.13 | $1,788.91 |