- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $8,980.00
| Facility | | $315.43 | $315.43 | $8,980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $455.00
| Professional | | $315.43 | $315.43 | $455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.34 / $64.06 / $149.49
| Professional | | $42.34 | $64.06 | $149.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.36 / $88.60 / $172.68
| Facility | | $35.36 | $88.60 | $172.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.50 / $3.10
| Professional | | $2.48 | $2.50 | $3.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.69 / $315.43 / $482.61
| Facility | | $161.69 | $315.43 | $482.61 |