- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.78 / $1,963.14 / $3,316.80
| Facility | | $451.78 | $1,963.14 | $3,316.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $381.30 / $453.03
| Professional | | $377.52 | $381.30 | $453.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.45 / $408.45 / $408.45
| Facility | | $408.45 | $408.45 | $408.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.44 / $408.45 / $408.45
| Professional | | $384.44 | $408.45 | $408.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.40 / $356.15 / $377.52
| Facility | | $253.40 | $356.15 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.64 / $377.52 / $483.23
| Professional | | $358.64 | $377.52 | $483.23 |