- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $2,691.53 / $4,365.16
| Facility | | $141.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $208.93
| Professional | | $141.25 | $141.25 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $724.44 / $1,445.44
| Facility | | $389.05 | $724.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $478.63 / $1,202.26
| Facility | | $190.55 | $478.63 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $323.59 / $512.86
| Professional | | $269.15 | $323.59 | $512.86 |