- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.15 / $287.52 / $6,497.15
| Facility | | $171.15 | $287.52 | $6,497.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.15 / $171.15 / $171.15
| Professional | | $171.15 | $171.15 | $171.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.20 / $463.20 / $463.20
| Professional | | $463.20 | $463.20 | $463.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.60 / $445.60 / $533.88
| Professional | | $445.60 | $445.60 | $533.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.15 / $183.13 / $273.83
| Facility | | $171.15 | $183.13 | $273.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.26 / $427.26 / $427.26
| Professional | | $427.26 | $427.26 | $427.26 |