- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.91 / $450.91 / $834.18
| Facility | | $450.91 | $450.91 | $834.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.08 / $293.08 / $450.91
| Professional | | $293.08 | $293.08 | $450.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.91 / $689.89 / $863.49
| Professional | | $450.91 | $689.89 | $863.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.58 / $1,713.46 / $1,713.46
| Facility | | $784.58 | $1,713.46 | $1,713.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.55 / $2,254.55 / $2,254.55
| Professional | | $2,254.55 | $2,254.55 | $2,254.55 |