- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.67 / $311.20 / $1,077.30
| Facility | | $256.67 | $311.20 | $1,077.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.67 / $266.30 / $320.83
| Professional | | $256.67 | $266.30 | $320.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.63 / $281.72 / $285.77
| Professional | | $238.63 | $281.72 | $285.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.38 / $206.72 / $272.70
| Professional | | $165.38 | $206.72 | $272.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.22 / $272.70 / $457.20
| Facility | | $151.22 | $272.70 | $457.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.37 / $267.37 / $1,219.19
| Professional | | $267.37 | $267.37 | $1,219.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.37 / $267.37 / $299.45
| Professional | | $267.37 | $267.37 | $299.45 |