- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.64 / $204.64 / $204.64
| Facility | | $204.64 | $204.64 | $204.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.19 / $204.64 / $234.97
| Professional | | $162.19 | $204.64 | $234.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.53 / $1,531.84 / $3,715.45
| Facility | | $797.53 | $1,531.84 | $3,715.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.37 / $773.60 / $797.53
| Professional | | $656.37 | $773.60 | $797.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.71 / $251.40 / $420.26
| Facility | | $196.71 | $251.40 | $420.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $1,274.00 / $1,274.00
| Professional | | $311.49 | $1,274.00 | $1,274.00 |