- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.17 / $497.10 / $1,443.00
| Facility | | $78.17 | $497.10 | $1,443.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.31 / $250.00 / $494.18
| Professional | | $140.31 | $250.00 | $494.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.62 / $76.62 / $83.36
| Facility | | $76.62 | $76.62 | $83.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.75 / $161.54 / $1,200.00
| Facility | | $41.75 | $161.54 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.81 / $130.76 / $185.27
| Professional | | $76.81 | $130.76 | $185.27 |