- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.05 / $259.49 / $6,907.00
| Facility | | $134.05 | $259.49 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.31 / $94.72 / $115.95
| Professional | | $51.31 | $94.72 | $115.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.76 / $90.03 / $155.88
| Professional | | $64.76 | $90.03 | $155.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.88 / $335.88 / $1,199.92
| Facility | | $335.88 | $335.88 | $1,199.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.78 / $143.76 / $214.96
| Professional | | $93.78 | $143.76 | $214.96 |