- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.79 / $70.79 / $70.79
| Facility | | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $64.57 / $83.18
| Professional | | $52.48 | $64.57 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $1,000.00
| Professional | | $562.34 | $660.69 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $75.86
| Professional | | $60.26 | $60.26 | $75.86 |