- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.96 / $281.87 / $1,713.77
| Facility | | $252.96 | $281.87 | $1,713.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.87 / $281.87 / $289.10
| Professional | | $281.87 | $281.87 | $289.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.37 / $361.37 / $494.17
| Professional | | $361.37 | $361.37 | $494.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.75 / $890.23 / $2,060.46
| Facility | | $656.75 | $890.23 | $2,060.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.96 / $361.37 / $448.10
| Facility | | $252.96 | $361.37 | $448.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.78 / $206.12 / $329.07
| Professional | | $151.78 | $206.12 | $329.07 |