- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.30 / $449.30 / $1,155.33
| Facility | | $449.30 | $449.30 | $1,155.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.83 / $545.57 / $962.77
| Professional | | $287.83 | $545.57 | $962.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.62 / $737.62 / $1,082.85
| Professional | | $737.62 | $737.62 | $1,082.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.11 / $487.81 / $1,155.33
| Facility | | $385.11 | $487.81 | $1,155.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.60 / $361.76 / $1,283.70
| Professional | | $147.60 | $361.76 | $1,283.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.60 / $654.69 / $1,091.15
| Professional | | $147.60 | $654.69 | $1,091.15 |