- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.56 / $7,202.48 / $9,337.60
| Facility | | $269.56 | $7,202.48 | $9,337.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.58 / $269.56 / $269.57
| Professional | | $169.58 | $269.56 | $269.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.44 / $308.04 / $362.71
| Professional | | $217.44 | $308.04 | $362.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.51 / $297.94 / $457.05
| Professional | | $257.51 | $297.94 | $457.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,202.48 / $7,202.48 / $9,337.60
| Facility | | $7,202.48 | $7,202.48 | $9,337.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.58 / $269.56 / $269.57
| Professional | | $169.58 | $269.56 | $269.57 |