- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $439.25 / $6,269.72
| Facility | | $203.58 | $439.25 | $6,269.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $256.76
| Professional | | $203.58 | $203.58 | $256.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.10 / $239.10 / $239.10
| Professional | | $239.10 | $239.10 | $239.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $218.37
| Facility | | $203.58 | $203.58 | $218.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $203.58
| Professional | | $203.58 | $203.58 | $203.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.80 / $1,029.40 / $1,029.40
| Facility | | $270.80 | $1,029.40 | $1,029.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $215.79 / $276.87
| Professional | | $203.58 | $215.79 | $276.87 |