- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,905.46
| Facility | | $549.54 | $794.33 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $380.19 / $912.01
| Professional | | $190.55 | $380.19 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $1,479.11
| Facility | | $616.60 | $758.58 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $380.19 / $741.31
| Professional | | $186.21 | $380.19 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $245.47 / $436.52
| Facility | | $89.13 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $2,570.40
| Professional | | $891.25 | $891.25 | $2,570.40 |