- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $380.19 / $741.31
| Facility | | $100.00 | $380.19 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $47.86 / $64.57
| Professional | | $39.81 | $47.86 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $58.88 / $67.61
| Professional | | $21.38 | $58.88 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $79.43 / $165.96
| Professional | | $56.23 | $79.43 | $165.96 |