- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.58 / $109.39 / $109.39
| Facility | | $70.58 | $109.39 | $109.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.58 / $109.39 / $117.63
| Professional | | $70.58 | $109.39 | $117.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.00 / $164.00 / $385.40
| Professional | | $164.00 | $164.00 | $385.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.33 / $3,728.65 / $3,728.65
| Facility | | $278.33 | $3,728.65 | $3,728.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.23 / $902.23 / $1,377.15
| Professional | | $902.23 | $902.23 | $1,377.15 |