- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.46 / $372.00 / $540.84
| Facility | | $63.46 | $372.00 | $540.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $32.50 / $474.84
| Professional | | $30.00 | $32.50 | $474.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.20 / $201.60 / $307.24
| Professional | | $61.20 | $201.60 | $307.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $400.00 / $542.75
| Professional | | $225.00 | $400.00 | $542.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.07 / $2,875.00 / $4,410.00
| Professional | | $84.07 | $2,875.00 | $4,410.00 |