- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,348.96
| Facility | | $389.05 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $457.09 / $676.08
| Professional | | $288.40 | $457.09 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $537.03 / $1,071.52
| Facility | | $436.52 | $537.03 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $389.05 / $602.56
| Professional | | $269.15 | $389.05 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $239.88 / $870.96
| Facility | | $165.96 | $239.88 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |