- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.70 / $693.11 / $1,205.40
| Facility | | $602.70 | $693.11 | $1,205.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.11 / $512.29 / $584.62
| Professional | | $470.11 | $512.29 | $584.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.15 / $191.92 / $258.19
| Facility | | $158.15 | $191.92 | $258.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.71 / $228.75 / $391.06
| Professional | | $169.71 | $228.75 | $391.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.76 / $489.70 / $1,304.56
| Facility | | $391.76 | $489.70 | $1,304.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.13 / $253.13 / $361.62
| Professional | | $253.13 | $253.13 | $361.62 |