- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.25 / $458.40 / $2,007.63
| Facility | | $217.25 | $458.40 | $2,007.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.70 / $159.36 / $217.25
| Professional | | $94.70 | $159.36 | $217.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.42 / $308.92 / $527.85
| Professional | | $113.42 | $308.92 | $527.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.11 / $51.11 / $260.70
| Professional | | $51.11 | $51.11 | $260.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $350.00 / $350.00
| Professional | | $350.00 | $350.00 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.43 / $386.66 / $645.50
| Professional | | $123.43 | $386.66 | $645.50 |