- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.89 / $470.11 / $2,858.27
| Facility | | $421.89 | $470.11 | $2,858.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.11 / $482.16 / $524.35
| Professional | | $470.11 | $482.16 | $524.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.70 / $602.70 / $824.19
| Professional | | $602.70 | $602.70 | $824.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.35 / $1,484.77 / $3,436.52
| Facility | | $1,095.35 | $1,484.77 | $3,436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.11 / $602.70 / $761.58
| Facility | | $470.11 | $602.70 | $761.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.13 / $361.62 / $548.82
| Professional | | $253.13 | $361.62 | $548.82 |