- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.10 / $155.10 / $155.10
| Facility | | $155.10 | $155.10 | $155.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.56 / $155.10 / $155.10
| Professional | | $118.56 | $155.10 | $155.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.01 / $5,031.64 / $12,757.34
| Facility | | $1,061.01 | $5,031.64 | $12,757.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.81 / $1,061.01 / $1,061.01
| Professional | | $848.81 | $1,061.01 | $1,061.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.08 / $262.12 / $318.35
| Facility | | $126.08 | $262.12 | $318.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.23 / $902.23 / $902.23
| Professional | | $902.23 | $902.23 | $902.23 |