- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.34 / $586.47 / $1,410.83
| Facility | | $413.34 | $586.47 | $1,410.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.80 / $461.68 / $706.42
| Professional | | $296.80 | $461.68 | $706.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.19 / $535.19 / $1,110.89
| Facility | | $336.19 | $535.19 | $1,110.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.48 / $414.35 / $638.29
| Professional | | $249.48 | $414.35 | $638.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.13 / $228.13 / $228.13
| Professional | | $228.13 | $228.13 | $228.13 |