- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $602.56 / $8,511.38
| Facility | | $154.88 | $602.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $380.19 / $602.56
| Professional | | $154.88 | $380.19 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $263.03 / $512.86
| Facility | | $154.88 | $263.03 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $416.87 / $512.86
| Professional | | $239.88 | $416.87 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $426.58 / $616.60
| Professional | | $239.88 | $426.58 | $616.60 |