- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.26 / $922.67 / $1,563.66
| Facility | | $408.26 | $922.67 | $1,563.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $325.58 / $408.26
| Professional | | $104.71 | $325.58 | $408.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.82 / $108.82 / $434.63
| Professional | | $58.82 | $108.82 | $434.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.85 / $67.05 / $244.41
| Professional | | $29.85 | $67.05 | $244.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.37 / $336.91 / $596.05
| Professional | | $286.37 | $336.91 | $596.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.01 / $351.51 / $643.32
| Professional | | $111.01 | $351.51 | $643.32 |