- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $794.33
| Professional | | $398.11 | $524.81 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $1,659.59
| Facility | | $1,258.93 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $138.04 / $467.74
| Professional | | $109.65 | $138.04 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $4,466.84
| Facility | | $3,311.31 | $3,890.45 | $4,466.84 |