- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.65 / $965.65 / $965.65
| Facility | | $965.65 | $965.65 | $965.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.65 / $965.65 / $965.65
| Professional | | $965.65 | $965.65 | $965.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.00 / $1,015.27 / $1,238.44
| Professional | | $971.00 | $1,015.27 | $1,238.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.86 / $984.86 / $984.86
| Professional | | $984.86 | $984.86 | $984.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.58 / $1,177.58 / $3,596.25
| Professional | | $1,177.58 | $1,177.58 | $3,596.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.54 / $903.82 / $1,280.41
| Professional | | $602.54 | $903.82 | $1,280.41 |