- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.92 / $437.92 / $4,584.72
| Facility | | $437.92 | $437.92 | $4,584.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.92 / $437.92 / $437.92
| Professional | | $437.92 | $437.92 | $437.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $432.80 / $528.78 / $561.94
| Facility | | $432.80 | $528.78 | $561.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.51 / $749.22 / $1,075.60
| Facility | | $541.51 | $749.22 | $1,075.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.64 / $377.52 / $420.26
| Professional | | $358.64 | $377.52 | $420.26 |