- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.41 / $430.39 / $1,137.16
| Facility | | $271.41 | $430.39 | $1,137.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.26 / $259.10 / $433.70
| Professional | | $216.26 | $259.10 | $433.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $345.40 / $345.40
| Professional | | $100.00 | $345.40 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $40.00
| Professional | | $30.00 | $30.00 | $40.00 |