- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.85 / $658.13 / $1,583.23
| Facility | | $463.85 | $658.13 | $1,583.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.77 / $450.77 / $792.74
| Professional | | $263.77 | $450.77 | $792.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.44 / $601.69 / $1,246.64
| Facility | | $409.44 | $601.69 | $1,246.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.55 / $405.67 / $707.59
| Professional | | $256.55 | $405.67 | $707.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.82 / $278.95 / $395.06
| Facility | | $182.82 | $278.95 | $395.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.00 / $1,306.17 / $1,306.17
| Professional | | $364.00 | $1,306.17 | $1,306.17 |