- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.22 / $1,421.19 / $1,863.28
| Facility | | $271.22 | $1,421.19 | $1,863.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.22 / $271.22 / $271.22
| Professional | | $271.22 | $271.22 | $271.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.58 / $264.92 / $830.34
| Facility | | $257.58 | $264.92 | $830.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.62 / $361.62 / $361.62
| Professional | | $361.62 | $361.62 | $361.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $346.55 / $361.62
| Facility | | $301.35 | $346.55 | $361.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $346.62 / $450.24
| Professional | | $301.35 | $346.62 | $450.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $126.57 / $180.81
| Professional | | $126.57 | $126.57 | $180.81 |