- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.54 / $940.54 / $940.54
| Facility | | $940.54 | $940.54 | $940.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.08 / $863.36 / $940.54
| Professional | | $465.08 | $863.36 | $940.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.23 / $1,256.60 / $1,516.54
| Professional | | $1,213.23 | $1,256.60 | $1,516.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.54 / $1,087.83 / $1,470.94
| Facility | | $940.54 | $1,087.83 | $1,470.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.30 / $628.30 / $628.30
| Professional | | $628.30 | $628.30 | $628.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.58 / $816.48 / $1,568.48
| Professional | | $326.58 | $816.48 | $1,568.48 |