- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.83 / $178.34 / $3,140.00
| Facility | | $94.83 | $178.34 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.44 / $245.77 / $284.01
| Professional | | $36.44 | $245.77 | $284.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $79.94 / $568.03
| Professional | | $47.53 | $79.94 | $568.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.15 / $176.15 / $176.15
| Facility | | $176.15 | $176.15 | $176.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.69 / $516.58 / $1,102.75
| Professional | | $376.69 | $516.58 | $1,102.75 |