- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.54 / $213.54 / $403.59
| Facility | | $213.54 | $213.54 | $403.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.05 / $157.04 / $162.51
| Professional | | $133.05 | $157.04 | $162.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,815.72 / $2,815.72 / $2,815.72
| Facility | | $2,815.72 | $2,815.72 | $2,815.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.91 / $252.33 / $572.11
| Professional | | $124.91 | $252.33 | $572.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.91 / $250.32 / $616.48
| Professional | | $151.91 | $250.32 | $616.48 |