- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $169.82 / $3,981.07
| Facility | | $93.33 | $169.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $131.83 / $478.63
| Professional | | $87.10 | $131.83 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $218.78 / $346.74
| Professional | | $83.18 | $218.78 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $151.36 / $602.56
| Facility | | $95.50 | $151.36 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $107.15 / $141.25
| Professional | | $91.20 | $107.15 | $141.25 |