- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.09 / $650.97 / $1,565.99
| Facility | | $417.09 | $650.97 | $1,565.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.42 / $224.81 / $259.56
| Professional | | $206.42 | $224.81 | $259.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.44 / $594.04 / $1,233.06
| Facility | | $361.44 | $594.04 | $1,233.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $204.38 / $204.38
| Professional | | $204.38 | $204.38 | $204.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.43 / $276.43 / $6,344.47
| Facility | | $276.43 | $276.43 | $6,344.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.20 / $1,080.20 / $1,080.20
| Professional | | $1,080.20 | $1,080.20 | $1,080.20 |