- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.97 / $736.97 / $1,017.73
| Facility | | $736.97 | $736.97 | $1,017.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.94 / $567.35 / $736.97
| Professional | | $350.94 | $567.35 | $736.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $441.02 / $1,049.32
| Facility | | $380.19 | $441.02 | $1,049.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.41 / $731.13 / $731.13
| Facility | | $526.41 | $731.13 | $731.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.66 / $350.94 / $795.46
| Professional | | $245.66 | $350.94 | $795.46 |