- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $338.84 / $3,981.07
| Facility | | $239.88 | $338.84 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $354.81
| Professional | | $239.88 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.51 / $2.51 / $4.27
| Professional | | $2.51 | $2.51 | $4.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $295.12 / $707.95
| Facility | | $239.88 | $295.12 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |