- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.44 / $2,487.42 / $2,487.42
| Facility | | $129.44 | $2,487.42 | $2,487.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.44 / $525.07 / $890.73
| Professional | | $129.44 | $525.07 | $890.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.92 / $730.11 / $1,235.56
| Professional | | $245.92 | $730.11 | $1,235.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.09 / $399.40 / $1,581.26
| Professional | | $182.09 | $399.40 | $1,581.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.44 / $554.22 / $1,662.66
| Facility | | $129.44 | $554.22 | $1,662.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.30 / $1,017.68 / $1,456.55
| Professional | | $558.30 | $1,017.68 | $1,456.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.78 / $1,083.94 / $1,456.55
| Professional | | $404.78 | $1,083.94 | $1,456.55 |