- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.74 / $307.91 / $8,586.85
| Facility | | $88.74 | $307.91 | $8,586.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.70 / $121.71 / $121.71
| Professional | | $121.70 | $121.71 | $121.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.63 / $101.00 / $101.00
| Professional | | $100.63 | $101.00 | $101.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.90 / $119.90 / $119.90
| Professional | | $119.90 | $119.90 | $119.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |