- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.74 / $1,400.16 / $1,886.74
| Facility | | $496.74 | $1,400.16 | $1,886.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Professional | | $496.74 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.50 / $764.92 / $1,293.42
| Professional | | $496.50 | $764.92 | $1,293.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.62 / $468.62 / $496.74
| Facility | | $468.62 | $468.62 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.23 / $422.23 / $496.74
| Professional | | $422.23 | $422.23 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.77 / $496.74 / $644.94
| Professional | | $491.77 | $496.74 | $644.94 |