- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.11 / $280.58 / $21,860.67
| Facility | | $212.11 | $280.58 | $21,860.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.18 / $164.54 / $280.58
| Professional | | $142.18 | $164.54 | $280.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.18 / $268.50 / $399.53
| Facility | | $142.18 | $268.50 | $399.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $1,351.44
| Professional | | $254.57 | $254.57 | $1,351.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $286.57
| Professional | | $254.57 | $254.57 | $286.57 |