- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $741.31 / $758.58
| Professional | | $724.44 | $741.31 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $1,445.44
| Facility | | $758.58 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $4,073.80
| Professional | | $758.58 | $758.58 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $1,995.26
| Professional | | $1,949.84 | $1,995.26 | $1,995.26 |