- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.42 / $1,658.25 / $2,358.96
| Facility | | $400.42 | $1,658.25 | $2,358.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.42 / $400.42 / $400.42
| Professional | | $400.42 | $400.42 | $400.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.39 / $419.39 / $513.54
| Professional | | $419.39 | $419.39 | $513.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.15 / $566.15 / $566.15
| Professional | | $566.15 | $566.15 | $566.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.31 / $488.31 / $1,491.25
| Professional | | $488.31 | $488.31 | $1,491.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.86 / $374.78 / $530.94
| Professional | | $249.86 | $374.78 | $530.94 |