- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.33 / $497.33 / $497.33
| Facility | | $497.33 | $497.33 | $497.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.33 / $593.72 / $743.98
| Professional | | $497.33 | $593.72 | $743.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.15 / $752.15 / $1,460.86
| Facility | | $752.15 | $752.15 | $1,460.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.07 / $549.07 / $1,605.75
| Professional | | $549.07 | $549.07 | $1,605.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.61 / $1,343.99 / $1,913.73
| Professional | | $1,334.61 | $1,343.99 | $1,913.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.62 / $1,460.86 / $1,460.86
| Professional | | $1,426.62 | $1,460.86 | $1,460.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.16 / $728.81 / $1,334.61
| Professional | | $595.16 | $728.81 | $1,334.61 |