- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.10 / $826.10 / $1,239.15
| Facility | | $826.10 | $826.10 | $1,239.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.10 / $826.10 / $988.26
| Professional | | $826.10 | $826.10 | $988.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $81.01 / $242.55
| Facility | | $37.47 | $81.01 | $242.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $736.38 / $920.47
| Professional | | $736.38 | $736.38 | $920.47 |