- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $151.36 / $288.40
| Professional | | $117.49 | $151.36 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $7,585.78
| Facility | | $1,318.26 | $3,162.28 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $933.25
| Professional | | $758.58 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $269.15 / $416.87
| Facility | | $151.36 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |