- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.82 / $1,391.28 / $1,391.28
| Facility | | $347.82 | $1,391.28 | $1,391.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.82 / $556.51 / $556.51
| Professional | | $347.82 | $556.51 | $556.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.44 / $301.44 / $301.44
| Facility | | $301.44 | $301.44 | $301.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.17 / $533.17 / $666.48
| Professional | | $533.17 | $533.17 | $666.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.44 / $440.57 / $556.51
| Facility | | $301.44 | $440.57 | $556.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.28 / $463.76 / $463.76
| Professional | | $380.28 | $463.76 | $463.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.78 / $194.78 / $278.26
| Professional | | $194.78 | $194.78 | $278.26 |