- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $977.24
| Professional | | $512.86 | $645.65 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,621.81
| Professional | | $912.01 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $1,905.46
| Facility | | $190.55 | $190.55 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,584.89
| Professional | | $891.25 | $1,230.27 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $575.44 / $1,096.48
| Facility | | $75.86 | $575.44 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $645.65 / $1,071.52
| Professional | | $467.74 | $645.65 | $1,071.52 |