- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.47 / $130.47 / $5,927.04
| Facility | | $130.47 | $130.47 | $5,927.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Professional | | $118.61 | $118.61 | $152.28 |
- 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
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.84 / $893.31 / $5,662.82
| Facility | | $738.84 | $893.31 | $5,662.82 |