- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $1,258.93
| Facility | | $190.55 | $190.55 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $251.19 / $380.19
| Professional | | $190.55 | $251.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $4,786.30 / $6,309.57
| Facility | | $501.19 | $4,786.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $549.54 / $794.33
| Professional | | $501.19 | $549.54 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $251.19 / $302.00
| Facility | | $245.47 | $251.19 | $302.00 |