- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $7,244.36
| Facility | | $512.86 | $512.86 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $107.15 / $169.82
| Professional | | $47.86 | $107.15 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $66.07 / $87.10
| Professional | | $40.74 | $66.07 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $69.18 / $69.18
| Professional | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $60.26 / $109.65
| Professional | | $39.81 | $60.26 | $109.65 |