- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.23 / $712.72 / $712.72
| Facility | | $349.23 | $712.72 | $712.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.72 / $712.72 / $1,432.35
| Professional | | $712.72 | $712.72 | $1,432.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.94 / $1,565.94 / $1,703.74
| Facility | | $1,565.94 | $1,565.94 | $1,703.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.31 / $486.37 / $1,774.36
| Facility | | $281.31 | $486.37 | $1,774.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.67 / $364.21 / $458.94
| Professional | | $225.67 | $364.21 | $458.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.01 / $1,471.00 / $2,749.48
| Professional | | $254.01 | $1,471.00 | $2,749.48 |