- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.26 / $242.65 / $1,344.00
| Facility | | $111.26 | $242.65 | $1,344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.43 / $112.75 / $175.97
| Professional | | $82.43 | $112.75 | $175.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.05 / $133.71 / $214.64
| Professional | | $90.05 | $133.71 | $214.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.97 / $1,035.97 / $1,035.97
| Facility | | $1,035.97 | $1,035.97 | $1,035.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $177.84 / $354.62
| Professional | | $138.74 | $177.84 | $354.62 |