- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,995.26 / $3,162.28
| Facility | | $407.38 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $512.86
| Professional | | $407.38 | $407.38 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $616.60
| Professional | | $295.12 | $346.74 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |