- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.14 / $1,358.03 / $1,829.97
| Facility | | $484.14 | $1,358.03 | $1,829.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.14 / $484.14 / $484.14
| Professional | | $484.14 | $484.14 | $484.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.57 / $723.41 / $1,223.22
| Professional | | $481.57 | $723.41 | $1,223.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.73 / $456.73 / $484.14
| Facility | | $456.73 | $456.73 | $484.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.52 / $411.52 / $484.14
| Professional | | $411.52 | $411.52 | $484.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.57 / $484.14 / $698.37
| Professional | | $440.57 | $484.14 | $698.37 |