- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $776.25 / $1,258.93
| Facility | | $223.87 | $776.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $912.01
| Professional | | $660.69 | $660.69 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,071.52 / $1,258.93
| Facility | | $512.86 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $1,412.54
| Facility | | $602.56 | $977.24 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $912.01 / $1,318.26
| Professional | | $660.69 | $912.01 | $1,318.26 |