- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.73 / $1,166.13 / $1,281.46
| Facility | | $640.73 | $1,166.13 | $1,281.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.18 / $698.40 / $1,217.39
| Professional | | $506.18 | $698.40 | $1,217.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.16 / $970.16 / $970.16
| Facility | | $970.16 | $970.16 | $970.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.16 / $970.16 / $970.16
| Professional | | $970.16 | $970.16 | $970.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.83 / $736.38 / $920.47
| Professional | | $291.83 | $736.38 | $920.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.11 / $320.37 / $1,093.71
| Professional | | $269.11 | $320.37 | $1,093.71 |