- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.43 / $622.98 / $1,077.35
| Facility | | $494.43 | $622.98 | $1,077.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.55 / $495.55 / $598.26
| Professional | | $495.55 | $495.55 | $598.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.55 / $495.55 / $495.55
| Facility | | $495.55 | $495.55 | $495.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.55 / $495.55 / $495.55
| Professional | | $495.55 | $495.55 | $495.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.34 / $2,422.00 / $2,477.75
| Facility | | $644.34 | $2,422.00 | $2,477.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.84 / $495.55 / $495.55
| Professional | | $476.84 | $495.55 | $495.55 |