- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.62 / $465.62 / $465.62
| Facility | | $465.62 | $465.62 | $465.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.62 / $565.82 / $823.79
| Professional | | $465.62 | $565.82 | $823.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.63 / $724.63 / $1,267.04
| Facility | | $724.63 | $724.63 | $1,267.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.98 / $528.98 / $1,109.46
| Professional | | $528.98 | $528.98 | $1,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.53 / $1,165.68 / $1,659.82
| Professional | | $1,157.53 | $1,165.68 | $1,659.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.33 / $1,267.04 / $1,267.04
| Professional | | $1,237.33 | $1,267.04 | $1,267.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.30 / $677.28 / $1,267.04
| Professional | | $571.30 | $677.28 | $1,267.04 |