- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.51 / $1,963.14 / $3,316.80
| Facility | | $377.51 | $1,963.14 | $3,316.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.51 / $377.52 / $453.03
| Professional | | $377.51 | $377.52 | $453.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.18 / $241.18 / $265.30
| Facility | | $241.18 | $241.18 | $265.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $369.97 / $377.52 / $377.52
| Facility | | $369.97 | $377.52 | $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
- $377.52 / $385.07 / $498.33
| Professional | | $377.52 | $385.07 | $498.33 |