- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $1,465.05 / $1,974.18
| Facility | | $508.96 | $1,465.05 | $1,974.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $508.96
| Professional | | $508.96 | $508.96 | $508.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $776.74 / $1,313.39
| Professional | | $508.96 | $776.74 | $1,313.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.15 / $480.15 / $508.96
| Facility | | $480.15 | $480.15 | $508.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.62 / $432.62 / $508.96
| Professional | | $432.62 | $432.62 | $508.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.15 / $508.96 / $824.91
| Professional | | $463.15 | $508.96 | $824.91 |