- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.68 / $1,193.04 / $1,564.16
| Facility | | $227.68 | $1,193.04 | $1,564.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.68 / $227.68 / $227.68
| Professional | | $227.68 | $227.68 | $227.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.18 / $165.77 / $519.57
| Facility | | $161.18 | $165.77 | $519.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.13 / $214.29 / $345.16
| Professional | | $113.13 | $214.29 | $345.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.57 / $216.86 / $808.99
| Facility | | $188.57 | $216.86 | $808.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.25 / $254.98 / $320.91
| Professional | | $203.25 | $254.98 | $320.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.14 / $152.77 / $264.61
| Professional | | $113.14 | $152.77 | $264.61 |