- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.00 / $515.85 / $515.85
| Facility | | $396.00 | $515.85 | $515.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.08 / $365.62 / $413.70
| Professional | | $345.08 | $365.62 | $413.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,196.11 / $2,196.11 / $2,196.11
| Facility | | $2,196.11 | $2,196.11 | $2,196.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.84 / $382.32 / $549.35
| Professional | | $243.84 | $382.32 | $549.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.83 / $401.19 / $1,020.91
| Professional | | $222.83 | $401.19 | $1,020.91 |