- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.17 / $94.17 / $211.23
| Facility | | $94.17 | $94.17 | $211.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.62 / $113.75 / $528.25
| Professional | | $86.62 | $113.75 | $528.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.65 / $209.33 / $1,148.32
| Professional | | $94.65 | $209.33 | $1,148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.48 / $245.62 / $1,148.32
| Professional | | $112.48 | $245.62 | $1,148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.96 / $487.88 / $2,096.69
| Professional | | $246.96 | $487.88 | $2,096.69 |