- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.68 / $292.70 / $1,779.62
| Facility | | $262.68 | $292.70 | $1,779.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.70 / $292.70 / $300.20
| Professional | | $292.70 | $292.70 | $300.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.25 / $394.01 / $517.85
| Professional | | $375.25 | $394.01 | $517.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.97 / $924.42 / $2,139.58
| Facility | | $681.97 | $924.42 | $2,139.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.70 / $375.25 / $450.30
| Facility | | $292.70 | $375.25 | $450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.61 / $206.39 / $341.71
| Professional | | $157.61 | $206.39 | $341.71 |