- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.68 / $5,001.80 / $7,778.60
| Facility | | $203.68 | $5,001.80 | $7,778.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.56 / $203.68 / $203.68
| Professional | | $127.56 | $203.68 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.08 / $231.73 / $272.61
| Professional | | $163.08 | $231.73 | $272.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.52 / $223.90 / $343.48
| Professional | | $193.52 | $223.90 | $343.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,001.80 / $5,001.80 / $7,778.60
| Facility | | $5,001.80 | $5,001.80 | $7,778.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $203.68 / $203.68
| Professional | | $134.83 | $203.68 | $203.68 |