- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $2,125.50 / $2,299.98
| Facility | | $175.28 | $2,125.50 | $2,299.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.75 / $175.28 / $347.19
| Professional | | $143.75 | $175.28 | $347.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,005.71 / $4,765.84
| Facility | | $1,935.29 | $3,005.71 | $4,765.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $215.59
| Facility | | $175.28 | $175.28 | $215.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.97 / $115.97 / $115.97
| Professional | | $115.97 | $115.97 | $115.97 |