- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.71 / $525.71 / $657.14
| Facility | | $525.71 | $525.71 | $657.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.51 / $657.14 / $823.33
| Professional | | $634.51 | $657.14 | $823.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.93 / $1,055.93 / $1,170.00
| Professional | | $1,055.93 | $1,055.93 | $1,170.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $665.68 / $1,680.75
| Facility | | $39.76 | $665.68 | $1,680.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $416.30 / $520.38
| Professional | | $416.30 | $416.30 | $520.38 |