- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $2,290.87
| Facility | | $257.04 | $257.04 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $288.40
| Professional | | $173.78 | $257.04 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $309.03 / $489.78
| Professional | | $218.78 | $309.03 | $489.78 |