- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $1,096.48
| Facility | | $39.81 | $57.54 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $1,202.26
| Professional | | $34.67 | $44.67 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $831.76 / $1,202.26
| Professional | | $707.95 | $831.76 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |