- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $1,995.26
| Facility | | $1,621.81 | $1,737.80 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $1,202.26
| Professional | | $524.81 | $794.33 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,096.48 / $1,202.26
| Facility | | $489.78 | $1,096.48 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $1,258.93
| Professional | | $524.81 | $794.33 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $2,290.87
| Facility | | $1,412.54 | $1,412.54 | $2,290.87 |