- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.33 / $584.33 / $584.33
| Facility | | $584.33 | $584.33 | $584.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.67 / $615.49 / $758.80
| Professional | | $481.67 | $615.49 | $758.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $736.40 / $883.67
| Professional | | $585.04 | $736.40 | $883.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.52 / $766.82 / $1,083.75
| Professional | | $75.52 | $766.82 | $1,083.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.98 / $4,936.52 / $5,116.51
| Facility | | $1,007.98 | $4,936.52 | $5,116.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.60 / $415.27 / $606.73
| Professional | | $277.60 | $415.27 | $606.73 |