- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $349.98 / $2,440.78
| Facility | | $118.61 | $349.98 | $2,440.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Professional | | $118.61 | $118.61 | $152.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.80 / $8.01 / $10.92
| Professional | | $6.80 | $8.01 | $10.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.34 / $98.34 / $100.00
| Professional | | $98.34 | $98.34 | $100.00 |