- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.75 / $477.75 / $836.06
| Facility | | $477.75 | $477.75 | $836.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $477.75 / $489.26
| Professional | | $460.48 | $477.75 | $489.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $528.86
| Facility | | $508.43 | $508.43 | $528.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Professional | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.60 / $2,644.30 / $2,644.30
| Facility | | $575.60 | $2,644.30 | $2,644.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.87 / $1,913.87 / $1,913.87
| Professional | | $1,913.87 | $1,913.87 | $1,913.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.54 / $575.60 / $661.94
| Professional | | $529.54 | $575.60 | $661.94 |