- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.58 / $848.05 / $2,040.10
| Facility | | $505.58 | $848.05 | $2,040.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.16 / $372.40 / $516.66
| Professional | | $296.16 | $372.40 | $516.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.49 / $775.32 / $1,606.38
| Facility | | $463.49 | $775.32 | $1,606.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.23 / $293.23 / $463.49
| Professional | | $293.23 | $293.23 | $463.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.34 / $359.34 / $359.34
| Facility | | $359.34 | $359.34 | $359.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.37 / $867.37 / $867.37
| Professional | | $867.37 | $867.37 | $867.37 |