- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.28 / $3,072.86 / $3,072.86
| Facility | | $140.28 | $3,072.86 | $3,072.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.03 / $163.92 / $308.18
| Professional | | $58.03 | $163.92 | $308.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.05 / $63.51 / $77.20
| Facility | | $59.05 | $63.51 | $77.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.63 / $68.63 / $83.64
| Professional | | $68.63 | $68.63 | $83.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.84 / $101.84 / $101.84
| Facility | | $101.84 | $101.84 | $101.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.63 / $203.73 / $580.37
| Professional | | $68.63 | $203.73 | $580.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.02 / $248.28 / $419.35
| Professional | | $186.02 | $248.28 | $419.35 |