- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $559.82 / $794.30 / $1,910.79
| Facility | | $559.82 | $794.30 | $1,910.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.87 / $292.60 / $316.70
| Professional | | $251.87 | $292.60 | $316.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.03 / $700.31 / $1,504.56
| Facility | | $441.03 | $700.31 | $1,504.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.38 / $249.38 / $266.00
| Professional | | $249.38 | $249.38 | $266.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.43 / $283.43 / $283.43
| Facility | | $283.43 | $283.43 | $283.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.51 / $1,471.51 / $1,471.51
| Professional | | $1,471.51 | $1,471.51 | $1,471.51 |