- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.14 / $409.71 / $1,115.50
| Facility | | $238.14 | $409.71 | $1,115.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $118.61
| Professional | | $118.61 | $118.61 | $118.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $124.54 / $201.64
| Facility | | $118.61 | $124.54 | $201.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |