- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.77 / $361.40 / $1,744.38
| Facility | | $213.77 | $361.40 | $1,744.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.77 / $213.77 / $213.77
| Professional | | $213.77 | $213.77 | $213.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.52 / $442.27 / $1,016.33
| Professional | | $199.52 | $442.27 | $1,016.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.18 / $481.70 / $1,035.60
| Facility | | $463.18 | $481.70 | $1,035.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.22 / $327.51 / $409.39
| Professional | | $156.22 | $327.51 | $409.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.38 / $579.38 / $579.38
| Professional | | $579.38 | $579.38 | $579.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.03 / $119.71 / $259.37
| Professional | | $62.03 | $119.71 | $259.37 |