- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.14 / $553.36 / $1,440.00
| Facility | | $102.14 | $553.36 | $1,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.02 / $102.14 / $108.49
| Professional | | $95.02 | $102.14 | $108.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.91 / $276.91 / $276.91
| Professional | | $276.91 | $276.91 | $276.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.90 / $119.90 / $119.90
| Professional | | $119.90 | $119.90 | $119.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.20 / $102.14 / $172.75
| Facility | | $70.20 | $102.14 | $172.75 |