- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $2,333.98
| Facility | | $748.07 | $748.07 | $2,333.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $748.07
| Professional | | $748.07 | $748.07 | $748.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.47 / $1,810.74 / $3,424.44
| Facility | | $1,042.47 | $1,810.74 | $3,424.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.91 / $794.83 / $794.83
| Professional | | $676.91 | $794.83 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $935.09 / $2,081.50
| Facility | | $748.07 | $935.09 | $2,081.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $794.23 / $953.07
| Professional | | $748.07 | $794.23 | $953.07 |