- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $47.86 / $107.15
| Professional | | $32.36 | $47.86 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $47.86 / $57.54
| Professional | | $41.69 | $47.86 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $2,290.87 / $3,630.78
| Facility | | $104.71 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $57.54 / $223.87
| Professional | | $38.02 | $57.54 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $46.77 / $77.62
| Professional | | $36.31 | $46.77 | $77.62 |