- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $512.86
| Facility | | $426.58 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $426.58 / $1,905.46
| Professional | | $398.11 | $426.58 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $3.98 / $3.98
| Professional | | $3.98 | $3.98 | $3.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,137.96 / $2,951.21
| Facility | | $724.44 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,905.46 / $1,995.26
| Professional | | $1,122.02 | $1,905.46 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $1,949.84
| Professional | | $1,318.26 | $1,905.46 | $1,949.84 |