- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.55 / $313.51 / $1,057.10
| Facility | | $129.55 | $313.51 | $1,057.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.55 / $129.55 / $134.72
| Professional | | $129.55 | $129.55 | $134.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.73 / $190.00 / $1,504.67
| Professional | | $172.73 | $190.00 | $1,504.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.68 / $291.89 / $628.51
| Facility | | $280.68 | $291.89 | $628.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.05 / $388.68 / $1,345.52
| Professional | | $111.05 | $388.68 | $1,345.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.64 / $351.11 / $351.11
| Professional | | $198.64 | $351.11 | $351.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.55 / $103.64 / $254.65
| Professional | | $72.55 | $103.64 | $254.65 |