- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.00 / $455.00 / $1,179.17
| Facility | | $455.00 | $455.00 | $1,179.17 |
- 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
- $45.39 / $45.39 / $45.39
| Facility | | $45.39 | $45.39 | $45.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.48 / $3.10
| Professional | | $2.48 | $2.48 | $3.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.20 / $103.83 / $149.72
| Facility | | $82.20 | $103.83 | $149.72 |