- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.15 / $2,273.87 / $3,199.84
| Facility | | $672.15 | $2,273.87 | $3,199.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $27.85 / $43.86
| Professional | | $13.25 | $27.85 | $43.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.62 / $30.62 / $30.62
| Professional | | $30.62 | $30.62 | $30.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.09 / $22.09 / $22.09
| Professional | | $22.09 | $22.09 | $22.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.27 / $55.82 / $68.78
| Professional | | $43.27 | $55.82 | $68.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $15.00 / $15.94
| Professional | | $15.00 | $15.00 | $15.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.20 / $19.20 / $36.78
| Professional | | $19.20 | $19.20 | $36.78 |