- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.79 / $462.25 / $1,112.00
| Facility | | $325.79 | $462.25 | $1,112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.58 / $184.31 / $346.58
| Professional | | $146.58 | $184.31 | $346.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.66 / $407.55 / $875.59
| Facility | | $256.66 | $407.55 | $875.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.13 / $145.13 / $197.37
| Professional | | $145.13 | $145.13 | $197.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.84 / $450.84 / $450.84
| Facility | | $450.84 | $450.84 | $450.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.92 / $608.92 / $608.92
| Professional | | $608.92 | $608.92 | $608.92 |