- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $489.78 / $524.81
| Professional | | $316.23 | $489.78 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,548.82
| Professional | | $1,047.13 | $1,174.90 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $1,659.59
| Facility | | $1,258.93 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $229.09 / $1,479.11
| Professional | | $181.97 | $229.09 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $4,466.84
| Facility | | $3,311.31 | $3,890.45 | $4,466.84 |