- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.29 / $1,492.85 / $2,011.64
| Facility | | $546.29 | $1,492.85 | $2,011.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.29 / $546.29 / $546.29
| Professional | | $546.29 | $546.29 | $546.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.37 / $847.94 / $1,433.78
| Professional | | $529.37 | $847.94 | $1,433.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.37 / $515.37 / $546.29
| Facility | | $515.37 | $515.37 | $546.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.35 / $464.35 / $546.29
| Professional | | $464.35 | $464.35 | $546.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.12 / $546.29 / $885.42
| Professional | | $497.12 | $546.29 | $885.42 |