- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.57 / $4,050.46 / $6,287.61
| Facility | | $345.57 | $4,050.46 | $6,287.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $110.59
| Professional | | $106.33 | $106.33 | $110.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.04 / $136.04 / $354.88
| Facility | | $136.04 | $136.04 | $354.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Facility | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $118.37
| Professional | | $106.33 | $106.33 | $118.37 |