- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.12 / $776.12 / $1,389.25
| Facility | | $776.12 | $776.12 | $1,389.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $776.12 / $776.12
| Professional | | $748.07 | $776.12 | $776.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Facility | | $794.83 | $794.83 | $794.83 |
- 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
- $888.34 / $3,853.40 / $3,853.40
| Facility | | $888.34 | $3,853.40 | $3,853.40 |