- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.09 / $417.11 / $5,043.35
| Facility | | $78.09 | $417.11 | $5,043.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.28 / $73.43 / $109.76
| Professional | | $61.28 | $73.43 | $109.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.16 / $93.65 / $107.84
| Professional | | $59.16 | $93.65 | $107.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,130.85 / $5,130.85 / $5,130.85
| Facility | | $5,130.85 | $5,130.85 | $5,130.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.70 / $92.70 / $92.70
| Professional | | $92.70 | $92.70 | $92.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.67 / $87.25 / $203.32
| Professional | | $63.67 | $87.25 | $203.32 |