- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,033.06 / $1,033.06 / $1,607.32
| Facility | | $1,033.06 | $1,033.06 | $1,607.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.23 / $0.23 / $0.23
| Professional | | $0.23 | $0.23 | $0.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.87 / $2.87 / $42.42
| Professional | | $2.87 | $2.87 | $42.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.69 / $638.11 / $941.25
| Facility | | $282.69 | $638.11 | $941.25 |