- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.12 / $607.62 / $4,299.16
| Facility | | $133.12 | $607.62 | $4,299.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.12 / $118.28 / $146.46
| Professional | | $78.12 | $118.28 | $146.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.94 / $154.53 / $182.97
| Professional | | $82.94 | $154.53 | $182.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.39 / $1,906.64 / $5,107.39
| Facility | | $603.39 | $1,906.64 | $5,107.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.95 / $117.95 / $151.18
| Professional | | $117.95 | $117.95 | $151.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.89 / $152.05 / $347.95
| Professional | | $108.89 | $152.05 | $347.95 |