- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $3,981.07
| Facility | | $213.80 | $213.80 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $81.28 / $354.81
| Professional | | $24.55 | $81.28 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $39.81 / $72.44
| Professional | | $19.50 | $39.81 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $60.26 / $128.82
| Professional | | $27.54 | $60.26 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $51.29 / $112.20
| Professional | | $25.70 | $51.29 | $112.20 |