- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $521.71 / $521.71 / $521.71
| Facility | | $521.71 | $521.71 | $521.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.25 / $400.49 / $521.71
| Professional | | $398.25 | $400.49 | $521.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.84 / $1,208.84 / $1,208.84
| Professional | | $1,208.84 | $1,208.84 | $1,208.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.49 / $521.71 / $933.59
| Facility | | $400.49 | $521.71 | $933.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,879.51 / $3,879.51 / $3,879.51
| Professional | | $3,879.51 | $3,879.51 | $3,879.51 |