- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.56 / $700.56 / $1,488.69
| Facility | | $700.56 | $700.56 | $1,488.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.45 / $567.45 / $567.45
| Professional | | $567.45 | $567.45 | $567.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.22 / $280.22 / $455.36
| Professional | | $280.22 | $280.22 | $455.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.56 / $700.56 / $1,134.91
| Facility | | $700.56 | $700.56 | $1,134.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.45 / $567.45 / $700.56
| Professional | | $567.45 | $567.45 | $700.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.29 / $420.34 / $1,225.98
| Professional | | $357.29 | $420.34 | $1,225.98 |