- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.87 / $167.58 / $280.50
| Professional | | $139.87 | $167.58 | $280.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.85 / $231.49 / $607.14
| Facility | | $150.85 | $231.49 | $607.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.10 / $184.00 / $309.10
| Professional | | $106.10 | $184.00 | $309.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.13 / $1,024.71 / $1,024.71
| Facility | | $204.13 | $1,024.71 | $1,024.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.00 / $1,138.00 / $1,138.00
| Professional | | $1,138.00 | $1,138.00 | $1,138.00 |