- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.16 / $315.43 / $315.43
| Facility | | $202.16 | $315.43 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $455.00
| Professional | | $315.43 | $315.43 | $455.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Facility | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Professional | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.99 / $45.66 / $94.39
| Facility | | $32.99 | $45.66 | $94.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.48 / $3.10
| Professional | | $2.48 | $2.48 | $3.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $20.00
| Professional | | $17.00 | $20.00 | $20.00 |