- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.78 / $310.00 / $378.53
| Facility | | $206.78 | $310.00 | $378.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.07 / $38.07 / $131.53
| Professional | | $38.07 | $38.07 | $131.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.61 / $143.75 / $143.75
| Professional | | $57.61 | $143.75 | $143.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.48 / $301.48 / $301.48
| Facility | | $301.48 | $301.48 | $301.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.12 / $233.42 / $421.96
| Professional | | $97.12 | $233.42 | $421.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.66 / $170.28 / $257.39
| Professional | | $16.66 | $170.28 | $257.39 |