- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $1,258.93
| Facility | | $194.98 | $194.98 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $245.47 / $323.59
| Professional | | $194.98 | $245.47 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $10,232.93 / $13,489.63
| Facility | | $676.08 | $10,232.93 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,071.52
| Professional | | $676.08 | $676.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $229.09 / $234.42
| Professional | | $181.97 | $229.09 | $234.42 |