- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $812.83
| Facility | | $281.84 | $354.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $134.90 / $4,168.69
| Professional | | $75.86 | $134.90 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $169.82 / $398.11
| Facility | | $104.71 | $169.82 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,570.88
| Professional | | $4,168.69 | $4,168.69 | $4,570.88 |