- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $479.25 / $679.63 / $1,634.95
| Facility | | $479.25 | $679.63 | $1,634.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.66 / $366.73 / $606.26
| Professional | | $291.66 | $366.73 | $606.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.36 / $621.35 / $1,287.35
| Facility | | $377.36 | $621.35 | $1,287.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.77 / $288.77 / $530.48
| Professional | | $288.77 | $288.77 | $530.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.52 / $294.73 / $364.80
| Facility | | $281.52 | $294.73 | $364.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.00 / $1,141.00 / $1,141.00
| Professional | | $1,141.00 | $1,141.00 | $1,141.00 |