- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.57 / $620.69 / $3,635.43
| Facility | | $58.57 | $620.69 | $3,635.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.85 / $58.57 / $63.19
| Professional | | $52.85 | $58.57 | $63.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $862.24 / $1,965.75 / $3,868.86
| Facility | | $862.24 | $1,965.75 | $3,868.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.81 / $114.81 / $245.16
| Professional | | $114.81 | $114.81 | $245.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.48 / $64.43 / $99.57
| Facility | | $49.48 | $64.43 | $99.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |