- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $700.44 / $3,963.98
| Facility | | $40.00 | $700.44 | $3,963.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $75.61
| Professional | | $30.00 | $45.00 | $75.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.38 / $128.38 / $128.38
| Professional | | $128.38 | $128.38 | $128.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.92 / $36.75 / $142.33
| Professional | | $13.92 | $36.75 | $142.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.00 / $60.00 / $87.98
| Professional | | $48.00 | $60.00 | $87.98 |