- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $1,698.24
| Facility | | $190.55 | $190.55 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $190.55 / $234.42
| Professional | | $151.36 | $190.55 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $4,365.16
| Facility | | $1,230.27 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $218.78 / $407.38
| Professional | | $151.36 | $218.78 | $407.38 |