- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,318.26 / $1,318.26
| Facility | | $831.76 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $213.80 / $275.42
| Professional | | $181.97 | $213.80 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $371.54 / $467.74
| Facility | | $123.03 | $371.54 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $512.86 / $870.96
| Facility | | $489.78 | $512.86 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |