- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.26 / $345.96 / $662.89
| Facility | | $145.26 | $345.96 | $662.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.98 / $211.64 / $1,397.00
| Professional | | $126.98 | $211.64 | $1,397.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.56 / $153.76 / $2,916.50
| Facility | | $133.56 | $153.76 | $2,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.82 / $139.82 / $178.05
| Professional | | $139.82 | $139.82 | $178.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.54 / $297.14 / $515.96
| Professional | | $124.54 | $297.14 | $515.96 |