- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $684.52 / $684.52 / $684.52
| Facility | | $684.52 | $684.52 | $684.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.52 / $684.52 / $684.52
| Professional | | $684.52 | $684.52 | $684.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.13 / $997.95 / $1,630.82
| Facility | | $368.13 | $997.95 | $1,630.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.78 / $1,002.49 / $1,604.32
| Facility | | $385.78 | $1,002.49 | $1,604.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.18 / $2,343.02 / $2,420.34
| Professional | | $335.18 | $2,343.02 | $2,420.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.14 / $1,008.89 / $1,604.32
| Facility | | $326.14 | $1,008.89 | $1,604.32 |