- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $213.80 / $3,981.07
| Facility | | $204.17 | $213.80 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $102.33 / $218.78
| Professional | | $45.71 | $102.33 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $87.10 / $158.49
| Professional | | $53.70 | $87.10 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $112.20 / $190.55
| Professional | | $54.95 | $112.20 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $81.28 / $165.96
| Professional | | $46.77 | $81.28 | $165.96 |