- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $1,819.70
| Facility | | $104.71 | $144.54 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $104.71 / $380.19
| Professional | | $83.18 | $104.71 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $89.13 / $251.19
| Professional | | $81.28 | $89.13 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $602.56 / $1,621.81
| Facility | | $346.74 | $602.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $120.23 / $275.42
| Professional | | $75.86 | $120.23 | $275.42 |