- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.73 / $223.72 / $372.00
| Facility | | $114.73 | $223.72 | $372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.38 / $114.73 / $114.73
| Professional | | $56.38 | $114.73 | $114.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.73 / $123.91 / $257.00
| Facility | | $114.73 | $123.91 | $257.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.12 / $197.12 / $197.12
| Professional | | $197.12 | $197.12 | $197.12 |