- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $318.22
| Facility | | $318.22 | $318.22 | $318.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $3,172.85
| Professional | | $318.22 | $318.22 | $3,172.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.63 / $755.45 / $1,104.78
| Facility | | $501.63 | $755.45 | $1,104.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.64 / $778.64 / $778.64
| Facility | | $778.64 | $778.64 | $778.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $391.41
| Facility | | $318.22 | $318.22 | $391.41 |