- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.78 / $165.70 / $389.90
| Professional | | $131.78 | $165.70 | $389.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.06 / $427.68 / $427.68
| Facility | | $209.06 | $427.68 | $427.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.58 / $2,940.00 / $2,940.00
| Professional | | $398.58 | $2,940.00 | $2,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $160.40 / $193.30
| Professional | | $128.69 | $160.40 | $193.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $85.00 / $85.00
| Facility | | $85.00 | $85.00 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $85.00 / $85.00
| Professional | | $77.00 | $85.00 | $85.00 |