- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.79 / $162.12 / $1,033.16
| Facility | | $107.79 | $162.12 | $1,033.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.66 / $162.12 / $251.35
| Professional | | $71.66 | $162.12 | $251.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.02 / $146.55 / $329.17
| Professional | | $130.02 | $146.55 | $329.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.89 / $1,308.89 / $1,308.89
| Facility | | $1,308.89 | $1,308.89 | $1,308.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.45 / $105.17 / $220.00
| Professional | | $70.45 | $105.17 | $220.00 |