- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.04 / $567.32 / $1,117.46
| Facility | | $127.04 | $567.32 | $1,117.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.23 / $127.04 / $127.04
| Professional | | $115.23 | $127.04 | $127.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.34 / $230.77 / $306.92
| Professional | | $200.34 | $230.77 | $306.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.50 / $909.34 / $1,027.06
| Facility | | $651.50 | $909.34 | $1,027.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.20 / $122.21 / $647.98
| Professional | | $113.20 | $122.21 | $647.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.43 / $300.68 / $300.68
| Professional | | $134.43 | $300.68 | $300.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.11 / $210.48 / $433.35
| Professional | | $115.11 | $210.48 | $433.35 |