- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $1,698.24
| Facility | | $34.67 | $44.67 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $2,238.72
| Professional | | $34.67 | $50.12 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $1,905.46
| Professional | | $1,513.56 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $2,691.53
| Facility | | $34.67 | $44.67 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $70.79 / $89.13
| Professional | | $47.86 | $70.79 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $64.57 / $83.18
| Professional | | $39.81 | $64.57 | $83.18 |