- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.21 / $933.66 / $3,793.15
| Facility | | $41.21 | $933.66 | $3,793.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.50 / $35.74 / $60.88
| Professional | | $6.50 | $35.74 | $60.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.44 / $67.81 / $67.81
| Professional | | $63.44 | $67.81 | $67.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.06 / $45.06 / $45.06
| Professional | | $45.06 | $45.06 | $45.06 |
- 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 |