- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $354.81 / $1,698.24
| Facility | | $245.47 | $354.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $257.04 / $389.05
| Professional | | $208.93 | $257.04 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $1,862.09
| Facility | | $436.52 | $436.52 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $1,778.28
| Professional | | $239.88 | $363.08 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $1,148.15
| Facility | | $457.09 | $457.09 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $316.23 / $501.19
| Professional | | $208.93 | $316.23 | $501.19 |