- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $724.44 / $1,698.24
| Facility | | $512.86 | $724.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $371.54 / $602.56
| Professional | | $295.12 | $371.54 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $1,348.96
| Facility | | $549.54 | $691.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $457.09
| Professional | | $288.40 | $288.40 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $288.40 / $407.38
| Facility | | $169.82 | $288.40 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |