- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.94 / $506.44 / $1,218.31
| Facility | | $356.94 | $506.44 | $1,218.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.38 / $311.54 / $607.03
| Professional | | $162.38 | $311.54 | $607.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.31 / $463.01 / $959.30
| Facility | | $290.31 | $463.01 | $959.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.78 / $282.13 / $517.16
| Professional | | $160.78 | $282.13 | $517.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.55 / $220.55 / $220.55
| Facility | | $220.55 | $220.55 | $220.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $1,017.00 / $1,017.00
| Professional | | $396.00 | $1,017.00 | $1,017.00 |