- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $3,981.07
| Facility | | $575.44 | $575.44 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $120.23 / $269.15
| Professional | | $51.29 | $120.23 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $67.61 / $102.33
| Professional | | $43.65 | $67.61 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $114.82 / $173.78
| Professional | | $69.18 | $114.82 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,412.54 / $6,456.54
| Facility | | $416.87 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $85.11 / $154.88
| Professional | | $48.98 | $85.11 | $154.88 |