- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.51 / $1,460.45 / $1,460.45
| Facility | | $436.51 | $1,460.45 | $1,460.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $558.73
| Professional | | $432.02 | $432.02 | $558.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $436.51
| Professional | | $432.02 | $432.02 | $436.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $550.22
| Professional | | $432.02 | $432.02 | $550.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $491.27
| Professional | | $432.02 | $432.02 | $491.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $457.94
| Professional | | $432.02 | $432.02 | $457.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.63 / $394.63 / $394.63
| Professional | | $394.63 | $394.63 | $394.63 |