- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.20 / $352.35 / $745.86
| Facility | | $262.20 | $352.35 | $745.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.19 / $190.44 / $234.60
| Professional | | $46.19 | $190.44 | $234.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $871.22
| Facility | | $0.02 | $0.03 | $871.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.40 / $57.66 / $207.00
| Professional | | $46.40 | $57.66 | $207.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.66 / $57.66 / $57.66
| Facility | | $57.66 | $57.66 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.66 / $57.66 / $57.66
| Professional | | $57.66 | $57.66 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.60 / $234.60 / $248.40
| Professional | | $234.60 | $234.60 | $248.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.92 / $276.00 / $303.60
| Professional | | $253.92 | $276.00 | $303.60 |