- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $1,230.27 / $1,230.27
| Facility | | $288.40 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $288.40
| Professional | | $245.47 | $245.47 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $1,737.80
| Facility | | $724.44 | $851.14 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $316.23 / $707.95
| Professional | | $218.78 | $316.23 | $707.95 |