- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Facility | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $798.15 / $798.15
| Professional | | $287.56 | $798.15 | $798.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.21 / $1,348.87 / $2,186.92
| Facility | | $411.21 | $1,348.87 | $2,186.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.21 / $734.21 / $856.57
| Facility | | $734.21 | $734.21 | $856.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,643.00 / $1,643.00 / $1,643.00
| Facility | | $1,643.00 | $1,643.00 | $1,643.00 |