- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.05 / $663.05 / $915.64
| Facility | | $663.05 | $663.05 | $915.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.74 / $663.05 / $663.05
| Professional | | $315.74 | $663.05 | $663.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $342.05 / $396.78 / $944.06
| Facility | | $342.05 | $396.78 | $944.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.63 / $604.63 / $755.79
| Professional | | $604.63 | $604.63 | $755.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.61 / $473.61 / $473.61
| Facility | | $473.61 | $473.61 | $473.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.02 / $315.74 / $526.23
| Professional | | $221.02 | $315.74 | $526.23 |