- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.73 / $274.73 / $274.73
| Facility | | $274.73 | $274.73 | $274.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $274.73 / $284.32
| Professional | | $128.16 | $274.73 | $284.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $1,989.38 / $2,486.71
| Professional | | $143.26 | $1,989.38 | $2,486.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.07 / $350.60 / $1,844.67
| Facility | | $254.07 | $350.60 | $1,844.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $3,742.91
| Professional | | $2,170.19 | $2,170.19 | $3,742.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $2,430.62
| Professional | | $2,170.19 | $2,170.19 | $2,430.62 |