- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.32 / $807.32 / $1,114.86
| Facility | | $807.32 | $807.32 | $1,114.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.44 / $807.32 / $807.32
| Professional | | $384.44 | $807.32 | $807.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.47 / $483.11 / $957.88
| Facility | | $416.47 | $483.11 | $957.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.63 / $668.63 / $835.78
| Professional | | $668.63 | $668.63 | $835.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $576.66 / $576.66 / $576.66
| Facility | | $576.66 | $576.66 | $576.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.11 / $384.44 / $640.73
| Professional | | $269.11 | $384.44 | $640.73 |