- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.52 / $693.32 / $693.32
| Professional | | $515.52 | $693.32 | $693.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.52 / $783.34 / $802.82
| Professional | | $662.52 | $783.34 | $802.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.63 / $969.22 / $1,218.72
| Professional | | $959.63 | $969.22 | $1,218.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.56 / $670.80 / $3,937.24
| Facility | | $340.56 | $670.80 | $3,937.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.29 / $530.25 / $589.16
| Professional | | $282.29 | $530.25 | $589.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.67 / $530.25 / $589.16
| Professional | | $235.67 | $530.25 | $589.16 |