- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.00 / $854.03 / $6,157.56
| Facility | | $153.00 | $854.03 | $6,157.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.03 / $854.03 / $854.03
| Professional | | $854.03 | $854.03 | $854.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.07 / $24.42 / $35.92
| Professional | | $19.07 | $24.42 | $35.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.70 / $59.70 / $59.70
| Facility | | $59.70 | $59.70 | $59.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.03 / $854.03 / $1,434.77
| Facility | | $854.03 | $854.03 | $1,434.77 |