- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $748.07
| Facility | | $748.07 | $748.07 | $748.07 |
- 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
- $849.37 / $1,324.71 / $2,050.96
| Facility | | $849.37 | $1,324.71 | $2,050.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.35 / $674.35 / $899.13
| Professional | | $674.35 | $674.35 | $899.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Facility | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $888.34 / $3,853.40
| Facility | | $748.07 | $888.34 | $3,853.40 |