- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $588.84
| Professional | | $575.44 | $575.44 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $575.44 / $1,122.02
| Professional | | $257.04 | $575.44 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $407.38 / $977.24
| Facility | | $363.08 | $407.38 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $575.44
| Professional | | $363.08 | $363.08 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $562.34 / $1,230.27
| Professional | | $457.09 | $562.34 | $1,230.27 |