- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.54 / $157.54 / $157.54
| Facility | | $157.54 | $157.54 | $157.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.38 / $152.03 / $257.36
| Professional | | $147.38 | $152.03 | $257.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.68 / $778.24 / $2,958.83
| Facility | | $745.68 | $778.24 | $2,958.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.19 / $272.30 / $334.43
| Professional | | $198.19 | $272.30 | $334.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.43 / $334.43 / $364.16
| Professional | | $334.43 | $334.43 | $364.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.90 / $377.86 / $776.25
| Professional | | $200.90 | $377.86 | $776.25 |