- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $891.25 / $977.24
| Facility | | $741.31 | $891.25 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $354.81 / $1,230.27
| Professional | | $316.23 | $354.81 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $354.81
| Facility | | $281.84 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $354.81 / $354.81
| Facility | | $302.00 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $346.74 / $549.54
| Professional | | $316.23 | $346.74 | $549.54 |