- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $2,187.76
| Facility | | $269.15 | $269.15 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $269.15 / $275.42
| Professional | | $3.98 | $269.15 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,380.38
| Facility | | $575.44 | $602.56 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $512.86
| Professional | | $407.38 | $407.38 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $446.68
| Professional | | $151.36 | $213.80 | $446.68 |