- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $645.65 / $645.65
| Facility | | $33.11 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $1,122.02
| Professional | | $30.20 | $47.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,071.52
| Professional | | $467.74 | $758.58 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $645.65 / $1,071.52
| Professional | | $177.83 | $645.65 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $478.63 / $1,174.90
| Professional | | $426.58 | $478.63 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $70.79 / $109.65
| Professional | | $52.48 | $70.79 | $109.65 |