- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.54 / $122.54 / $122.54
| Facility | | $122.54 | $122.54 | $122.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.40 / $122.54 / $122.54
| Professional | | $103.40 | $122.54 | $122.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.15 / $117.15 / $306.74
| Professional | | $117.15 | $117.15 | $306.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $1,427.00 / $1,998.00
| Facility | | $200.00 | $1,427.00 | $1,998.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.40 / $198.01 / $277.93
| Professional | | $154.40 | $198.01 | $277.93 |