- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $218.78 / $1,288.25
| Facility | | $112.20 | $218.78 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $2,137.96
| Professional | | $43.65 | $43.65 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |