- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $1,798.32
| Facility | | $846.27 | $846.27 | $1,798.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $846.27
| Professional | | $846.27 | $846.27 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.51 / $338.51 / $550.07
| Professional | | $338.51 | $338.51 | $550.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $1,013.92 / $1,502.04
| Professional | | $846.27 | $1,013.92 | $1,502.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $1,370.96
| Facility | | $846.27 | $846.27 | $1,370.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $846.27
| Professional | | $846.27 | $846.27 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.60 / $507.76 / $1,480.97
| Professional | | $431.60 | $507.76 | $1,480.97 |