- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,584.89 / $1,949.84
| Facility | | $512.86 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $537.03
| Professional | | $512.86 | $512.86 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $776.25 / $1,621.81
| Professional | | $676.08 | $776.25 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $512.86 / $512.86
| Facility | | $478.63 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $512.86
| Professional | | $426.58 | $426.58 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $831.76
| Professional | | $512.86 | $512.86 | $831.76 |