- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $1,148.15 / $1,148.15
| Facility | | $56.23 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $56.23 / $1,148.15
| Professional | | $38.02 | $56.23 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $870.96
| Professional | | $501.19 | $645.65 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $478.63 / $724.44
| Professional | | $213.80 | $478.63 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $776.25 / $977.24
| Professional | | $630.96 | $776.25 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $50.12 / $79.43
| Professional | | $38.02 | $50.12 | $79.43 |