- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.04 / $30.50 / $2,192.60
| Facility | | $25.04 | $30.50 | $2,192.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.28 / $146.58 / $161.36
| Professional | | $137.28 | $146.58 | $161.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.61 / $455.04 / $729.83
| Facility | | $280.61 | $455.04 | $729.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,738.50 / $1,738.50 / $1,738.50
| Facility | | $1,738.50 | $1,738.50 | $1,738.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.99 / $1,663.99 / $1,663.99
| Professional | | $1,663.99 | $1,663.99 | $1,663.99 |