- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.62 / $543.08 / $1,411.20
| Facility | | $461.62 | $543.08 | $1,411.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Professional | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.33 / $135.60 / $203.40
| Facility | | $131.33 | $135.60 | $203.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.62 / $506.88 / $506.88
| Facility | | $461.62 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $689.71
| Professional | | $506.88 | $506.88 | $689.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.57 / $543.08 / $577.87
| Professional | | $452.57 | $543.08 | $577.87 |