- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.45 / $621.03 / $1,074.70
| Facility | | $440.45 | $621.03 | $1,074.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.54 / $430.09 / $440.45
| Professional | | $357.54 | $430.09 | $440.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.07 / $457.73 / $503.50
| Facility | | $389.07 | $457.73 | $503.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.73 / $457.73 / $457.73
| Professional | | $457.73 | $457.73 | $457.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.45 / $440.45 / $440.45
| Professional | | $440.45 | $440.45 | $440.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.17 / $518.17 / $591.97
| Professional | | $518.17 | $518.17 | $591.97 |