- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.36 / $863.36 / $863.36
| Facility | | $863.36 | $863.36 | $863.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.02 / $863.36 / $863.36
| Professional | | $518.02 | $863.36 | $863.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.07 / $1,287.07 / $1,415.78
| Facility | | $1,287.07 | $1,287.07 | $1,415.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.88 / $1,150.88 / $1,150.88
| Professional | | $1,150.88 | $1,150.88 | $1,150.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.45 / $293.45 / $293.45
| Professional | | $293.45 | $293.45 | $293.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.39 / $1,186.36 / $1,751.11
| Professional | | $311.39 | $1,186.36 | $1,751.11 |