- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $2,813.13
| Facility | | $308.72 | $308.72 | $2,813.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.03 / $240.32 / $323.31
| Facility | | $198.03 | $240.32 | $323.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.29 / $2,235.29 / $2,235.29
| Professional | | $2,235.29 | $2,235.29 | $2,235.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |