- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $426.58
| Professional | | $316.23 | $316.23 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $389.05 / $389.05
| Professional | | $151.36 | $389.05 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $602.56 / $1,096.48
| Facility | | $316.23 | $602.56 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,071.52
| Facility | | $501.19 | $794.33 | $1,071.52 |