- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.55 / $713.47 / $1,262.66
| Facility | | $189.55 | $713.47 | $1,262.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.82 / $205.80 / $284.32
| Professional | | $136.82 | $205.80 | $284.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Facility | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,844.67 / $2,170.19 / $2,170.19
| Facility | | $1,844.67 | $2,170.19 | $2,170.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,742.91 / $3,742.91 / $3,742.91
| Professional | | $3,742.91 | $3,742.91 | $3,742.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.69 / $2,170.19 / $2,170.19
| Professional | | $2,061.69 | $2,170.19 | $2,170.19 |