- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.64 / $1,288.63 / $1,288.63
| Facility | | $121.64 | $1,288.63 | $1,288.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.25 / $110.00 / $138.31
| Professional | | $87.25 | $110.00 | $138.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.00 / $578.00 / $578.00
| Professional | | $352.00 | $578.00 | $578.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.95 / $215.93 / $408.90
| Professional | | $116.95 | $215.93 | $408.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.10 / $282.08 / $481.00
| Professional | | $146.10 | $282.08 | $481.00 |