- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.12 / $2,400.07 / $4,641.68
| Facility | | $875.12 | $2,400.07 | $4,641.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $11.16 / $109.61
| Professional | | $11.16 | $11.16 | $109.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.16 / $11.72 / $18.97
| Facility | | $11.16 | $11.72 | $18.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.45 / $578.79 / $578.79
| Professional | | $506.45 | $578.79 | $578.79 |