- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $501.19 / $851.14
| Facility | | $269.15 | $501.19 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,258.93 / $2,041.74
| Facility | | $398.11 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $31.62
| Professional | | $30.20 | $30.20 | $31.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,698.24 / $2,570.40
| Facility | | $380.19 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $50.12
| Professional | | $47.86 | $47.86 | $50.12 |