- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.75 / $165.75 / $2,210.04
| Facility | | $165.75 | $165.75 | $2,210.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.21 / $217.11 / $4,825.60
| Professional | | $138.21 | $217.11 | $4,825.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.88 / $458.88 / $458.88
| Facility | | $458.88 | $458.88 | $458.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.10 / $387.93 / $387.93
| Professional | | $293.10 | $387.93 | $387.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.69 / $304.02 / $377.72
| Professional | | $159.69 | $304.02 | $377.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.75 / $228.09 / $319.47
| Professional | | $130.75 | $228.09 | $319.47 |