- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.43 / $1,988.21 / $2,606.67
| Facility | | $379.43 | $1,988.21 | $2,606.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.78 / $369.44 / $406.63
| Professional | | $341.78 | $369.44 | $406.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.07 / $143.07 / $143.07
| Facility | | $143.07 | $143.07 | $143.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.73 / $323.85 / $471.95
| Facility | | $246.73 | $323.85 | $471.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.00 / $180.00 / $200.00
| Professional | | $136.00 | $180.00 | $200.00 |