- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $602.56 / $1,122.02
| Facility | | $245.47 | $602.56 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $288.40
| Professional | | $245.47 | $245.47 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $489.78
| Professional | | $371.54 | $371.54 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $1,698.24
| Facility | | $1,258.93 | $1,479.11 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |