- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.26 / $215.76 / $306.23
| Facility | | $14.26 | $215.76 | $306.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.13 / $116.13 / $116.13
| Professional | | $116.13 | $116.13 | $116.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $51.00 / $51.00
| Professional | | $51.00 | $51.00 | $51.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.72 / $2,500.00 / $2,500.00
| Professional | | $132.72 | $2,500.00 | $2,500.00 |