- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.73 / $971.95 / $1,567.72
| Facility | | $831.73 | $971.95 | $1,567.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.13 / $366.89 / $439.58
| Professional | | $346.13 | $366.89 | $439.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $598.37 / $598.37 / $598.37
| Facility | | $598.37 | $598.37 | $598.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $598.37 / $598.37 / $598.37
| Facility | | $598.37 | $598.37 | $598.37 |