- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.07 / $853.52 / $1,689.26
| Facility | | $241.07 | $853.52 | $1,689.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.74 / $317.60 / $317.60
| Professional | | $207.74 | $317.60 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.32 / $230.32 / $230.32
| Facility | | $230.32 | $230.32 | $230.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.04 / $672.90 / $974.24
| Facility | | $248.04 | $672.90 | $974.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.93 / $194.93 / $194.93
| Professional | | $194.93 | $194.93 | $194.93 |