- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.40 / $956.40 / $1,320.75
| Facility | | $956.40 | $956.40 | $1,320.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $736.28 / $956.40
| Professional | | $455.43 | $736.28 | $956.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.38 / $572.32 / $1,134.77
| Facility | | $493.38 | $572.32 | $1,134.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.15 / $683.15 / $683.15
| Facility | | $683.15 | $683.15 | $683.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.80 / $455.43 / $759.05
| Professional | | $318.80 | $455.43 | $759.05 |