- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.93 / $816.90 / $1,004.30
| Facility | | $373.93 | $816.90 | $1,004.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.71 / $317.60 / $317.60
| Professional | | $211.71 | $317.60 | $317.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.53 / $210.35 / $230.23
| Professional | | $178.53 | $210.35 | $230.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $140.25 / $175.31
| Professional | | $116.76 | $140.25 | $175.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.74 / $317.60 / $509.12
| Facility | | $207.74 | $317.60 | $509.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.50 / $279.50 / $279.50
| Professional | | $279.50 | $279.50 | $279.50 |