- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.26 / $489.26 / $498.26
| Facility | | $489.26 | $489.26 | $498.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $477.75 / $489.26
| Professional | | $460.48 | $477.75 | $489.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.91 / $582.38 / $1,441.14
| Facility | | $241.91 | $582.38 | $1,441.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.26 / $505.89 / $575.60
| Professional | | $498.26 | $505.89 | $575.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $528.86
| Facility | | $508.43 | $508.43 | $528.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $551.60
| Professional | | $508.43 | $508.43 | $551.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.60 / $575.60 / $661.94
| Professional | | $575.60 | $575.60 | $661.94 |