- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.66 / $172.66 / $976.65
| Facility | | $172.66 | $172.66 | $976.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.42 / $547.40 / $976.65
| Professional | | $126.42 | $547.40 | $976.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.24 / $1,539.07 / $2,070.54
| Facility | | $1,268.24 | $1,539.07 | $2,070.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.93 / $860.02 / $1,634.03
| Professional | | $166.93 | $860.02 | $1,634.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.42 / $265.42 / $486.02
| Facility | | $265.42 | $265.42 | $486.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.50 / $496.82 / $1,508.06
| Professional | | $128.50 | $496.82 | $1,508.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.90 / $733.62 / $1,093.08
| Professional | | $457.90 | $733.62 | $1,093.08 |