- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.08 / $134.97 / $134.97
| Facility | | $87.08 | $134.97 | $134.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.12 / $87.54 / $139.33
| Professional | | $73.12 | $87.54 | $139.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $211.50
| Professional | | $90.00 | $90.00 | $211.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.35 / $1,246.93 / $1,246.93
| Facility | | $400.35 | $1,246.93 | $1,246.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.90 / $1,283.58 / $1,982.10
| Professional | | $1,260.90 | $1,283.58 | $1,982.10 |