- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.13 / $244.12 / $268.26
| Facility | | $134.13 | $244.12 | $268.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.96 / $244.12 / $268.26
| Professional | | $105.96 | $244.12 | $268.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.37 / $181.08 / $181.08
| Facility | | $174.37 | $181.08 | $181.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Professional | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.33 / $80.48 / $228.02
| Professional | | $56.33 | $80.48 | $228.02 |