- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.22 / $452.22 / $452.22
| Facility | | $452.22 | $452.22 | $452.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.27 / $452.22 / $500.98
| Professional | | $345.27 | $452.22 | $500.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.37 / $1,127.55 / $1,218.32
| Professional | | $1,017.37 | $1,127.55 | $1,218.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.22 / $499.68 / $768.77
| Facility | | $452.22 | $499.68 | $768.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.69 / $2,436.69 / $2,436.69
| Professional | | $2,436.69 | $2,436.69 | $2,436.69 |