- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.51 / $657.16 / $1,074.21
| Facility | | $505.51 | $657.16 | $1,074.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $611.66
| Professional | | $508.76 | $508.76 | $611.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.04 / $563.04 / $563.04
| Professional | | $563.04 | $563.04 | $563.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Facility | | $508.76 | $508.76 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Professional | | $508.76 | $508.76 | $508.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.98 / $2,423.75 / $2,423.75
| Facility | | $644.98 | $2,423.75 | $2,423.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.35 / $508.76 / $508.76
| Professional | | $507.35 | $508.76 | $508.76 |