- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $3,981.07
| Facility | | $239.88 | $239.88 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $64.57 / $112.20
| Professional | | $41.69 | $64.57 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $47.86 / $72.44
| Professional | | $36.31 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $58.88 / $109.65
| Professional | | $34.67 | $58.88 | $109.65 |
- 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
- $38.02 / $58.88 / $91.20
| Professional | | $38.02 | $58.88 | $91.20 |