- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $426.58
| Professional | | $251.19 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $223.87
| Professional | | $151.36 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $660.69 / $1,071.52
| Facility | | $331.13 | $660.69 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,071.52
| Facility | | $501.19 | $794.33 | $1,071.52 |