- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.27 / $257.27 / $3,955.04
| Facility | | $257.27 | $257.27 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.55 / $34.29 / $42.77
| Professional | | $21.55 | $34.29 | $42.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.54 / $40.04 / $62.83
| Professional | | $24.54 | $40.04 | $62.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.96 / $46.30 / $92.67
| Professional | | $24.96 | $46.30 | $92.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.25 / $57.89 / $85.10
| Professional | | $37.25 | $57.89 | $85.10 |