- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $5,495.41
| Facility | | $109.65 | $109.65 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $46.77 / $114.82
| Professional | | $42.66 | $46.77 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $85.11
| Professional | | $39.81 | $57.54 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- 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
- $38.02 / $52.48 / $83.18
| Professional | | $38.02 | $52.48 | $83.18 |