- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $856.84 / $856.84 / $856.84
| Facility | | $856.84 | $856.84 | $856.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.84 / $856.84 / $856.84
| Professional | | $856.84 | $856.84 | $856.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.30 / $2,102.30 / $2,102.30
| Professional | | $2,102.30 | $2,102.30 | $2,102.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.65 / $1,675.65 / $3,060.09
| Professional | | $1,675.65 | $1,675.65 | $3,060.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.67 / $1,019.76 / $1,433.35
| Professional | | $609.67 | $1,019.76 | $1,433.35 |