- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $338.84 / $8,511.38
| Facility | | $190.55 | $338.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $213.80 / $416.87
| Professional | | $190.55 | $213.80 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $371.54 / $562.34
| Facility | | $190.55 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $512.86 / $630.96
| Professional | | $288.40 | $512.86 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $6,309.57
| Facility | | $4,677.35 | $5,128.61 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $467.74 / $630.96
| Professional | | $288.40 | $467.74 | $630.96 |