- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.35 / $1,270.35 / $1,270.35
| Facility | | $1,270.35 | $1,270.35 | $1,270.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $798.38 / $798.38
| Professional | | $513.41 | $798.38 | $798.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.54 / $478.54 / $478.54
| Facility | | $478.54 | $478.54 | $478.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.24 / $504.24 / $504.24
| Facility | | $504.24 | $504.24 | $504.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.29 / $636.29 / $636.29
| Professional | | $636.29 | $636.29 | $636.29 |