- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.75 / $758.75 / $1,138.13
| Facility | | $758.75 | $758.75 | $1,138.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.75 / $785.65 / $1,089.15
| Professional | | $758.75 | $785.65 | $1,089.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $81.01 / $242.55
| Facility | | $37.47 | $81.01 | $242.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |