- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.25 / $430.25 / $430.25
| Facility | | $430.25 | $430.25 | $430.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.25 / $550.53 / $696.17
| Professional | | $430.25 | $550.53 | $696.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.52 / $723.52 / $1,265.07
| Facility | | $723.52 | $723.52 | $1,265.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.16 / $528.16 / $1,107.74
| Professional | | $528.16 | $528.16 | $1,107.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.74 / $1,163.85 / $1,657.24
| Professional | | $1,155.74 | $1,163.85 | $1,657.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.42 / $1,265.07 / $1,265.07
| Professional | | $1,235.42 | $1,265.07 | $1,265.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.86 / $631.13 / $1,265.07
| Professional | | $569.86 | $631.13 | $1,265.07 |