- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.74 / $1,257.42 / $1,386.24
| Facility | | $289.74 | $1,257.42 | $1,386.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.07 / $202.44 / $228.31
| Professional | | $191.07 | $202.44 | $228.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.48 / $635.48 / $635.48
| Facility | | $635.48 | $635.48 | $635.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $240.59 / $299.70
| Professional | | $153.91 | $240.59 | $299.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,087.83 / $1,087.83 / $1,087.83
| Facility | | $1,087.83 | $1,087.83 | $1,087.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.46 / $240.90 / $545.96
| Professional | | $179.46 | $240.90 | $545.96 |