- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.52 / $785.65 / $785.65
| Facility | | $628.52 | $785.65 | $785.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $785.65 / $1,046.84
| Professional | | $785.65 | $785.65 | $1,046.84 |
- 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
- $1,024.05 / $1,309.25 / $1,544.92
| Professional | | $1,024.05 | $1,309.25 | $1,544.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |