- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.65 / $673.65 / $673.65
| Facility | | $673.65 | $673.65 | $673.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.65 / $673.65 / $673.65
| Professional | | $673.65 | $673.65 | $673.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.33 / $1,001.33 / $1,001.33
| Professional | | $1,001.33 | $1,001.33 | $1,001.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.17 / $687.17 / $687.17
| Professional | | $687.17 | $687.17 | $687.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.85 / $1,069.85 / $3,267.28
| Professional | | $1,069.85 | $1,069.85 | $3,267.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.41 / $821.14 / $1,537.21
| Professional | | $547.41 | $821.14 | $1,537.21 |