- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $1,047.13
| Facility | | $34.67 | $44.67 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $1,380.38
| Professional | | $34.67 | $50.12 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,148.15
| Professional | | $891.25 | $1,071.52 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $2,691.53
| Facility | | $34.67 | $44.67 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $70.79 / $89.13
| Professional | | $47.86 | $70.79 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $64.57 / $83.18
| Professional | | $39.81 | $64.57 | $83.18 |