- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $836.47
| Facility | | $836.47 | $836.47 | $836.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.07 / $678.75 / $742.91
| Professional | | $576.07 | $678.75 | $742.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $646.13 / $807.66
| Professional | | $360.74 | $646.13 | $807.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,547.47
| Facility | | $836.47 | $836.47 | $1,547.47 |