- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $2,353.67
| Facility | | $690.18 | $690.18 | $2,353.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $1,010.42
| Professional | | $690.18 | $690.18 | $1,010.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.21 / $1,184.35 / $1,893.67
| Facility | | $689.21 | $1,184.35 | $1,893.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.47 / $941.47 / $941.47
| Facility | | $941.47 | $941.47 | $941.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.67 / $734.67 / $734.67
| Facility | | $734.67 | $734.67 | $734.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $509.60
| Professional | | $240.52 | $240.52 | $509.60 |