- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $558.46 / $1,575.14 / $2,122.53
| Facility | | $558.46 | $1,575.14 | $2,122.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $558.46 / $558.46
| Professional | | $558.46 | $558.46 | $558.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $848.23 / $1,434.28
| Professional | | $558.46 | $848.23 | $1,434.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.85 / $526.85 / $558.46
| Facility | | $526.85 | $526.85 | $558.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.69 / $474.69 / $558.46
| Professional | | $474.69 | $474.69 | $558.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $558.46 / $905.14
| Professional | | $558.46 | $558.46 | $905.14 |