- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $933.25 / $1,698.24
| Facility | | $338.84 | $933.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $338.84 / $549.54
| Professional | | $316.23 | $338.84 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $1,174.90
| Professional | | $588.84 | $912.01 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $741.31 / $1,445.44
| Facility | | $117.49 | $741.31 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $204.17 / $588.84
| Professional | | $186.21 | $204.17 | $588.84 |