- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.83 / $340.83 / $340.83
| Facility | | $340.83 | $340.83 | $340.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.83 / $391.11 / $558.04
| Professional | | $340.83 | $391.11 | $558.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.58 / $695.50 / $927.46
| Facility | | $508.58 | $695.50 | $927.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.72 / $507.72 / $812.12
| Professional | | $507.72 | $507.72 | $812.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.31 / $853.26 / $1,214.97
| Professional | | $847.31 | $853.26 | $1,214.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.72 / $927.46 / $927.46
| Professional | | $905.72 | $927.46 | $927.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.74 / $462.70 / $927.46
| Professional | | $411.74 | $462.70 | $927.46 |