- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.01 / $109.86 / $226.21
| Facility | | $103.01 | $109.86 | $226.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.94 / $150.44 / $226.21
| Professional | | $100.94 | $150.44 | $226.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.00 / $395.00 / $395.00
| Professional | | $395.00 | $395.00 | $395.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.74 / $151.44 / $259.68
| Professional | | $94.74 | $151.44 | $259.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.65 / $234.08 / $454.75
| Professional | | $124.65 | $234.08 | $454.75 |