- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.68 / $682.02 / $1,640.70
| Facility | | $480.68 | $682.02 | $1,640.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.68 / $368.02 / $616.03
| Professional | | $292.68 | $368.02 | $616.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.69 / $601.32 / $1,291.89
| Facility | | $378.69 | $601.32 | $1,291.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.77 / $289.77 / $545.30
| Professional | | $289.77 | $289.77 | $545.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.48 / $288.39 / $376.65
| Facility | | $72.48 | $288.39 | $376.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.00 / $1,842.00 / $1,842.00
| Professional | | $1,842.00 | $1,842.00 | $1,842.00 |