- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.62 / $107.62 / $257.51
| Facility | | $107.62 | $107.62 | $257.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.07 / $107.62 / $107.62
| Professional | | $101.07 | $107.62 | $107.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.01 / $1,501.20 / $3,715.45
| Facility | | $450.01 | $1,501.20 | $3,715.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.93 / $404.91 / $404.91
| Professional | | $323.93 | $404.91 | $404.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.82 / $181.88 / $221.11
| Facility | | $122.82 | $181.88 | $221.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.88 / $677.88 / $677.88
| Professional | | $677.88 | $677.88 | $677.88 |