- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $776.25
| Professional | | $616.60 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $776.25 / $831.76
| Facility | | $575.44 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $141.25 / $141.25
| Professional | | $112.20 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,548.82
| Facility | | $616.60 | $616.60 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $2,454.71
| Facility | | $1,737.80 | $1,778.28 | $2,454.71 |