- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.02 / $460.60 / $1,427.11
| Facility | | $91.02 | $460.60 | $1,427.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.59 / $44.59 / $2,126.41
| Professional | | $44.59 | $44.59 | $2,126.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.89 / $87.58 / $1,021.39
| Facility | | $66.89 | $87.58 | $1,021.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.08 / $34.83 / $34.83
| Facility | | $34.08 | $34.83 | $34.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.96 / $33.17 / $34.83
| Professional | | $30.96 | $33.17 | $34.83 |