- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $1,096.48
| Facility | | $223.87 | $223.87 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $275.42 / $346.74
| Professional | | $223.87 | $275.42 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $2,630.27
| Facility | | $1,778.28 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $2,754.23
| Professional | | $1,412.54 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $223.87 / $263.03
| Facility | | $194.98 | $223.87 | $263.03 |