- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.40 / $532.00 / $2,579.14
| Facility | | $106.40 | $532.00 | $2,579.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.00 / $120.35 / $123.25
| Professional | | $116.00 | $120.35 | $123.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.75 / $45.00 / $45.00
| Professional | | $42.75 | $45.00 | $45.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.25 / $123.25 / $123.25
| Facility | | $123.25 | $123.25 | $123.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.54 / $80.54 / $123.25
| Professional | | $80.54 | $80.54 | $123.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.34 / $123.25 / $188.57
| Professional | | $98.34 | $123.25 | $188.57 |