- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $1,412.54
| Facility | | $177.83 | $177.83 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $177.83 / $229.09
| Professional | | $125.89 | $177.83 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $562.34
| Facility | | $457.09 | $457.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $363.08 / $562.34
| Professional | | $257.04 | $363.08 | $562.34 |