- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,288.25 / $1,995.26
| Facility | | $549.54 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $208.93 / $371.54
| Professional | | $173.78 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $288.40 / $416.87
| Professional | | $173.78 | $288.40 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $1,659.59
| Facility | | $338.84 | $588.84 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $389.05
| Professional | | $169.82 | $208.93 | $389.05 |