- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.87 / $267.38 / $2,105.54
| Facility | | $241.87 | $267.38 | $2,105.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $272.52
| Professional | | $245.30 | $245.30 | $272.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.87 / $251.26 / $251.26
| Professional | | $241.87 | $251.26 | $251.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Facility | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.61 / $266.13 / $323.08
| Professional | | $179.61 | $266.13 | $323.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |