- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $134.90 / $239.88
| Facility | | $131.83 | $134.90 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $100.00 / $120.23
| Professional | | $97.72 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $11.75 / $11.75
| Professional | | $11.75 | $11.75 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,128.61 / $7,079.46
| Facility | | $1,380.38 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $25.70 / $25.70
| Professional | | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $208.93
| Facility | | $131.83 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $114.82
| Professional | | $102.33 | $102.33 | $114.82 |