- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.31 / $330.31 / $396.37
| Facility | | $330.31 | $330.31 | $396.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.37 / $461.36 / $507.49
| Professional | | $396.37 | $461.36 | $507.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.24 / $461.36 / $461.36
| Facility | | $435.24 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $669.62
| Professional | | $461.36 | $461.36 | $669.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $1,107.26
| Professional | | $461.36 | $461.36 | $1,107.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.42 / $348.06 / $442.99
| Professional | | $316.42 | $348.06 | $442.99 |