- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.73 / $950.00 / $2,825.00
| Facility | | $73.73 | $950.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $64.89 / $93.65
| Professional | | $50.00 | $64.89 | $93.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.50 / $50.00 / $80.00
| Professional | | $42.50 | $50.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.54 / $134.54 / $134.54
| Facility | | $134.54 | $134.54 | $134.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.02 / $80.89 / $173.84
| Professional | | $63.02 | $80.89 | $173.84 |