- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $842.26 / $842.26
| Facility | | $308.72 | $842.26 | $842.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- 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
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.89 / $1,964.89 / $1,964.89
| Facility | | $1,964.89 | $1,964.89 | $1,964.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.29 / $636.29 / $636.29
| Professional | | $636.29 | $636.29 | $636.29 |