- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.09 / $1,067.09 / $2,680.09
| Facility | | $1,067.09 | $1,067.09 | $2,680.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $344.75
| Professional | | $328.34 | $328.34 | $344.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.92 / $302.92 / $752.25
| Facility | | $302.92 | $302.92 | $752.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Facility | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $365.51
| Professional | | $328.34 | $328.34 | $365.51 |