- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.09 / $452.00 / $1,104.00
| Facility | | $94.09 | $452.00 | $1,104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.57 / $94.09 / $111.44
| Professional | | $35.57 | $94.09 | $111.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.08 / $78.08 / $78.08
| Professional | | $78.08 | $78.08 | $78.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.65 / $113.70 / $119.53
| Professional | | $96.65 | $113.70 | $119.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.15 / $117.86 / $203.06
| Professional | | $72.15 | $117.86 | $203.06 |