- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $141.25 / $181.97
| Facility | | $125.89 | $141.25 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $100.00 / $141.25
| Professional | | $85.11 | $100.00 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $173.78 / $199.53
| Professional | | $123.03 | $173.78 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $109.65 / $213.80
| Professional | | $89.13 | $109.65 | $213.80 |