- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.77 / $548.53 / $855.80
| Facility | | $274.77 | $548.53 | $855.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.91 / $1,251.76 / $2,020.54
| Facility | | $534.91 | $1,251.76 | $2,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.45 / $31.97
| Professional | | $30.00 | $30.45 | $31.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.12 / $377.12 / $450.87
| Facility | | $377.12 | $377.12 | $450.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |