- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.66 / $867.66 / $867.66
| Facility | | $867.66 | $867.66 | $867.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.66 / $867.66 / $867.66
| Professional | | $867.66 | $867.66 | $867.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.00 / $873.00 / $1,112.78
| Professional | | $873.00 | $873.00 | $1,112.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.35 / $653.35 / $653.35
| Professional | | $653.35 | $653.35 | $653.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.08 / $1,058.08 / $3,231.34
| Professional | | $1,058.08 | $1,058.08 | $3,231.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.40 / $812.11 / $1,150.48
| Professional | | $541.40 | $812.11 | $1,150.48 |