- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $512.86
| Professional | | $457.09 | $457.09 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,162.28
| Facility | | $1,995.26 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $794.33
| Professional | | $501.19 | $501.19 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $354.81 / $371.54
| Facility | | $346.74 | $354.81 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $537.03
| Professional | | $457.09 | $512.86 | $537.03 |