- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.02 / $198.02 / $1,217.70
| Facility | | $198.02 | $198.02 | $1,217.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $635.91 / $635.91
| Professional | | $198.02 | $635.91 | $635.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.27 / $777.27 / $1,141.06
| Professional | | $777.27 | $777.27 | $1,141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.02 / $405.90 / $1,014.75
| Facility | | $198.02 | $405.90 | $1,014.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $353.60 / $811.80
| Professional | | $144.27 | $353.60 | $811.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $288.54 / $565.76
| Professional | | $144.27 | $288.54 | $565.76 |