- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.36 / $245.36 / $245.36
| Facility | | $245.36 | $245.36 | $245.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.87 / $213.28 / $215.30
| Professional | | $201.87 | $213.28 | $215.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,594.50 / $6,553.50 / $11,163.11
| Facility | | $3,594.50 | $6,553.50 | $11,163.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.71 / $306.02 / $424.59
| Professional | | $217.71 | $306.02 | $424.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.36 / $190.36 / $216.31
| Professional | | $190.36 | $190.36 | $216.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.63 / $164.76 / $290.38
| Professional | | $113.63 | $164.76 | $290.38 |