- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $1,430.69
| Facility | | $748.07 | $748.07 | $1,430.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $935.09 / $935.09
| Professional | | $748.07 | $935.09 | $935.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.20 / $822.29 / $832.85
| Facility | | $818.20 | $822.29 | $832.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $2,244.21
| Facility | | $748.07 | $748.07 | $2,244.21 |