- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.09 / $3,772.63 / $3,772.63
| Facility | | $53.09 | $3,772.63 | $3,772.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.78 / $53.09 / $55.25
| Professional | | $42.78 | $53.09 | $55.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.28 / $2,154.98 / $3,868.86
| Facility | | $984.28 | $2,154.98 | $3,868.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.67 / $53.09 / $90.25
| Facility | | $37.67 | $53.09 | $90.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |