- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.21 / $497.26 / $1,436.19
| Facility | | $95.21 | $497.26 | $1,436.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.50 / $115.05 / $204.52
| Professional | | $35.50 | $115.05 | $204.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.34 / $83.73 / $258.52
| Professional | | $38.34 | $83.73 | $258.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.67 / $440.67 / $440.67
| Facility | | $440.67 | $440.67 | $440.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.21 / $60.37 / $63.69
| Professional | | $33.21 | $60.37 | $63.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.72 / $167.29 / $380.88
| Professional | | $129.72 | $167.29 | $380.88 |