- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.56 / $126.56 / $1,032.75
| Facility | | $126.56 | $126.56 | $1,032.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.56 / $126.56 / $131.63
| Professional | | $126.56 | $126.56 | $131.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.11 / $135.00 / $251.83
| Professional | | $128.11 | $135.00 | $251.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.23 / $285.19 / $613.04
| Facility | | $274.23 | $285.19 | $613.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $533.86 / $1,315.86
| Professional | | $101.72 | $533.86 | $1,315.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.06 / $343.02 / $343.02
| Professional | | $194.06 | $343.02 | $343.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.88 / $101.25 / $268.31
| Professional | | $70.88 | $101.25 | $268.31 |