- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.72 / $983.72 / $983.72
| Facility | | $983.72 | $983.72 | $983.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.72 / $983.72 / $983.72
| Professional | | $983.72 | $983.72 | $983.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.15 / $1,695.82 / $2,142.02
| Facility | | $251.15 | $1,695.82 | $2,142.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.94 / $1,185.20 / $1,185.20
| Professional | | $1,125.94 | $1,185.20 | $1,185.20 |