- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $933.25 / $1,698.24
| Facility | | $263.03 | $933.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $316.23 / $549.54
| Professional | | $263.03 | $316.23 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $575.44 / $616.60
| Professional | | $263.03 | $575.44 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $741.31 / $1,445.44
| Facility | | $117.49 | $741.31 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $616.60 / $776.25
| Professional | | $602.56 | $616.60 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $467.74 / $549.54
| Professional | | $131.83 | $467.74 | $549.54 |