- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $1,288.25 / $1,380.38
| Facility | | $50.12 | $1,288.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,412.54
| Professional | | $30.20 | $44.67 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.66 / $61.66 / $61.66
| Facility | | $61.66 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,122.02 / $2,137.96
| Professional | | $630.96 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $52.48 / $70.79
| Professional | | $44.67 | $52.48 | $70.79 |