- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.65 / $438.65 / $438.65
| Facility | | $438.65 | $438.65 | $438.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.65 / $530.30 / $717.84
| Professional | | $438.65 | $530.30 | $717.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.02 / $714.02 / $1,288.53
| Facility | | $714.02 | $714.02 | $1,288.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.23 / $521.23 / $1,128.28
| Professional | | $521.23 | $521.23 | $1,128.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.16 / $1,185.45 / $1,687.97
| Professional | | $1,177.16 | $1,185.45 | $1,687.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.33 / $1,288.53 / $1,288.53
| Professional | | $1,258.33 | $1,288.53 | $1,288.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.62 / $642.83 / $1,182.93
| Professional | | $517.62 | $642.83 | $1,182.93 |