- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.03 / $2,694.57 / $2,694.57
| Facility | | $245.03 | $2,694.57 | $2,694.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.20 / $58.63 / $61.50
| Professional | | $57.20 | $58.63 | $61.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.43 / $114.44 / $228.00
| Professional | | $114.43 | $114.44 | $228.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.00 / $16.00 / $78.59
| Facility | | $16.00 | $16.00 | $78.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.00 / $120.00 / $1,251.00
| Facility | | $54.00 | $120.00 | $1,251.00 |