- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Facility | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Professional | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.57 / $452.57 / $452.57
| Professional | | $452.57 | $452.57 | $452.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $506.88
| Facility | | $506.88 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $581.52
| Professional | | $506.88 | $506.88 | $581.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.57 / $511.40 / $543.08
| Professional | | $452.57 | $511.40 | $543.08 |