- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.37 / $178.28 / $8,731.31
| Facility | | $69.37 | $178.28 | $8,731.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $69.37 / $87.40
| Professional | | $69.37 | $69.37 | $87.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.58 / $75.58 / $75.58
| Facility | | $75.58 | $75.58 | $75.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $69.37 / $69.37
| Professional | | $69.37 | $69.37 | $69.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $74.17 / $152.61
| Professional | | $69.37 | $74.17 | $152.61 |