- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,318.26 / $1,659.59
| Facility | | $380.19 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $602.56
| Professional | | $316.23 | $371.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $263.03 / $588.84
| Professional | | $223.87 | $263.03 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $954.99
| Facility | | $204.17 | $363.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |