- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $524.81 / $549.54
| Facility | | $30.20 | $524.81 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $50.12 / $537.03
| Professional | | $30.20 | $50.12 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $3.72 / $5.50
| Professional | | $3.72 | $3.72 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $288.40 / $398.11
| Professional | | $181.97 | $288.40 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $354.81 / $380.19
| Professional | | $208.93 | $354.81 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |