- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $676.08
| Facility | | $34.67 | $34.67 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $47.86 / $870.96
| Professional | | $34.67 | $47.86 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $831.76
| Professional | | $354.81 | $524.81 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $77.62 / $138.04
| Professional | | $46.77 | $77.62 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $69.18 / $104.71
| Professional | | $39.81 | $69.18 | $104.71 |