- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.32 / $221.32 / $221.32
| Facility | | $221.32 | $221.32 | $221.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.32 / $412.22 / $1,098.49
| Professional | | $221.32 | $412.22 | $1,098.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.54 / $1,188.36 / $2,243.75
| Facility | | $266.54 | $1,188.36 | $2,243.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.22 / $351.14 / $508.76
| Professional | | $155.22 | $351.14 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.05 / $374.73 / $704.80
| Professional | | $185.05 | $374.73 | $704.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.07 / $254.38 / $558.29
| Professional | | $151.07 | $254.38 | $558.29 |