- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.55 / $766.55 / $766.55
| Facility | | $766.55 | $766.55 | $766.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.86 / $737.61 / $766.55
| Professional | | $695.86 | $737.61 | $766.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.12 / $1,164.76 / $1,193.74
| Professional | | $985.12 | $1,164.76 | $1,193.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.75 / $1,030.96 / $1,296.34
| Professional | | $1,020.75 | $1,030.96 | $1,296.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.67 / $766.55 / $4,115.68
| Facility | | $407.67 | $766.55 | $4,115.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.11 / $591.35 / $839.49
| Professional | | $366.11 | $591.35 | $839.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.82 / $591.35 / $839.49
| Professional | | $262.82 | $591.35 | $839.49 |