- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $588.62
| Facility | | $588.62 | $588.62 | $588.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $588.62
| Professional | | $588.62 | $588.62 | $588.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.50 / $1,228.50 / $1,842.75
| Facility | | $1,228.50 | $1,228.50 | $1,842.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.50 / $1,228.50 / $1,253.07
| Professional | | $1,228.50 | $1,228.50 | $1,253.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.73 / $528.73 / $528.73
| Facility | | $528.73 | $528.73 | $528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |