- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.73 / $92.21 / $5,012.45
| Facility | | $51.73 | $92.21 | $5,012.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.73 / $51.73 / $51.73
| Professional | | $51.73 | $51.73 | $51.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.17 / $57.27 / $57.71
| Facility | | $44.17 | $57.27 | $57.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.60 / $44.60 / $44.60
| Professional | | $44.60 | $44.60 | $44.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.60 / $44.60 / $106.33
| Facility | | $44.60 | $44.60 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.37 / $44.60 / $44.60
| Professional | | $42.37 | $44.60 | $44.60 |