- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $457.09 / $3,548.13
| Facility | | $151.36 | $457.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $229.09 / $457.09
| Professional | | $151.36 | $229.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $229.09 / $331.13
| Professional | | $173.78 | $229.09 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $3,162.28
| Facility | | $977.24 | $977.24 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $204.17 / $331.13
| Professional | | $151.36 | $204.17 | $331.13 |