- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.41 / $765.41 / $1,120.11
| Facility | | $765.41 | $765.41 | $1,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.41 / $1,120.11 / $1,260.13
| Professional | | $765.41 | $1,120.11 | $1,260.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.73 / $606.73 / $606.73
| Facility | | $606.73 | $606.73 | $606.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $793.42 / $793.42 / $1,064.10
| Facility | | $793.42 | $793.42 | $1,064.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.42 / $793.42 / $793.42
| Professional | | $793.42 | $793.42 | $793.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.75 / $777.86 / $1,011.22
| Professional | | $746.75 | $777.86 | $1,011.22 |