- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.80 / $896.80 / $896.80
| Facility | | $896.80 | $896.80 | $896.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.44 / $896.80 / $896.80
| Professional | | $667.44 | $896.80 | $896.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.68 / $3,055.68 / $3,055.68
| Professional | | $3,055.68 | $3,055.68 | $3,055.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,321.62 / $4,321.62 / $5,177.79
| Professional | | $4,321.62 | $4,321.62 | $5,177.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.98 / $63.58 / $149.46
| Professional | | $40.98 | $63.58 | $149.46 |