- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.71 / $935.00 / $966.12
| Facility | | $130.71 | $935.00 | $966.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.89 / $114.42 / $234.80
| Professional | | $49.89 | $114.42 | $234.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.81 / $137.76 / $338.76
| Professional | | $56.81 | $137.76 | $338.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.43 / $377.43 / $1,133.08
| Facility | | $377.43 | $377.43 | $1,133.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.71 / $52.71 / $96.50
| Professional | | $52.71 | $52.71 | $96.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.86 / $207.11 / $447.26
| Professional | | $156.86 | $207.11 | $447.26 |