- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $2,789.24
| Facility | | $118.61 | $118.61 | $2,789.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Professional | | $118.61 | $118.61 | $152.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.61 / $2,196.16 / $3,798.60
| Facility | | $1,517.61 | $2,196.16 | $3,798.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $195.71 / $231.29
| Facility | | $118.61 | $195.71 | $231.29 |