- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.38 / $195.38 / $1,594.26
| Facility | | $195.38 | $195.38 | $1,594.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.38 / $195.38 / $203.19
| Professional | | $195.38 | $195.38 | $203.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.70 / $208.40 / $208.40
| Professional | | $45.70 | $208.40 | $208.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.33 / $440.26 / $947.53
| Facility | | $423.33 | $440.26 | $947.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.84 / $374.28 / $2,030.41
| Professional | | $142.84 | $374.28 | $2,030.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.58 / $529.52 / $529.52
| Professional | | $299.58 | $529.52 | $529.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.41 / $156.30 / $414.20
| Professional | | $109.41 | $156.30 | $414.20 |