- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.18 / $130.11 / $162.63
| Professional | | $105.18 | $130.11 | $162.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.06 / $229.28 / $1,300.00
| Facility | | $156.06 | $229.28 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.00 / $876.00 / $876.00
| Professional | | $347.00 | $876.00 | $876.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.48 / $70.48 / $265.00
| Facility | | $70.48 | $70.48 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.48 / $127.90 / $265.00
| Professional | | $70.48 | $127.90 | $265.00 |