- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.56 / $431.56 / $431.56
| Facility | | $431.56 | $431.56 | $431.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.56 / $431.56 / $473.77
| Professional | | $431.56 | $431.56 | $473.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.39 / $305.70 / $357.47
| Professional | | $288.39 | $305.70 | $357.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.25 / $1,001.82 / $1,617.12
| Professional | | $773.25 | $1,001.82 | $1,617.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.56 / $609.78 / $1,294.68
| Facility | | $431.56 | $609.78 | $1,294.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.25 / $816.39 / $1,027.33
| Professional | | $478.25 | $816.39 | $1,027.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.46 / $869.54 / $1,027.33
| Professional | | $481.46 | $869.54 | $1,027.33 |