- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.66 / $877.59 / $3,198.84
| Facility | | $644.66 | $877.59 | $3,198.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.90 / $723.72 / $790.62
| Professional | | $364.90 | $723.72 | $790.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.16 / $608.16 / $608.16
| Facility | | $608.16 | $608.16 | $608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.31 / $4,296.10 / $4,618.20
| Facility | | $395.31 | $4,296.10 | $4,618.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.43 / $547.35 / $608.16
| Facility | | $255.43 | $547.35 | $608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.43 / $364.90 / $851.44
| Professional | | $255.43 | $364.90 | $851.44 |