- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $831.76 / $891.25
| Facility | | $30.20 | $831.76 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $851.14
| Professional | | $30.20 | $57.54 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.72 / $6.61
| Professional | | $3.02 | $3.72 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $501.19 / $691.83
| Professional | | $323.59 | $501.19 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $602.56
| Professional | | $338.84 | $562.34 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |