- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.42 / $466.42 / $466.42
| Facility | | $466.42 | $466.42 | $466.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.42 / $466.42 / $466.42
| Professional | | $466.42 | $466.42 | $466.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $756.02 / $1,271.79 / $1,548.65
| Facility | | $756.02 | $1,271.79 | $1,548.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.52 / $1,266.30 / $2,591.17
| Facility | | $1,072.52 | $1,266.30 | $2,591.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.41 / $307.70 / $329.56
| Facility | | $302.41 | $307.70 | $329.56 |