- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $308.72
| Facility | | $308.72 | $308.72 | $308.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $620.86
| Professional | | $308.72 | $308.72 | $620.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,005.71 / $4,765.84
| Facility | | $1,935.29 | $3,005.71 | $4,765.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.42 / $455.42 / $569.27
| Facility | | $455.42 | $455.42 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.48 / $837.48 / $837.48
| Professional | | $837.48 | $837.48 | $837.48 |