- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.81 / $576.91 / $1,387.84
| Facility | | $406.81 | $576.91 | $1,387.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.57 / $311.31 / $514.63
| Professional | | $247.57 | $311.31 | $514.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.33 / $527.44 / $1,092.79
| Facility | | $320.33 | $527.44 | $1,092.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.12 / $245.12 / $450.30
| Professional | | $245.12 | $245.12 | $450.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.39 / $118.68 / $253.48
| Facility | | $112.39 | $118.68 | $253.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.24 / $648.24 / $648.24
| Professional | | $648.24 | $648.24 | $648.24 |