- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.72 / $474.37 / $2,884.17
| Facility | | $425.72 | $474.37 | $2,884.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.37 / $474.37 / $529.11
| Professional | | $474.37 | $474.37 | $529.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.16 / $608.16 / $831.67
| Professional | | $608.16 | $608.16 | $831.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.25 / $1,233.36 / $3,467.66
| Facility | | $405.25 | $1,233.36 | $3,467.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.29 / $608.16 / $650.74
| Facility | | $468.29 | $608.16 | $650.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.43 / $304.08 / $553.80
| Professional | | $255.43 | $304.08 | $553.80 |