- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.38 / $163.33 / $163.33
| Facility | | $105.38 | $163.33 | $163.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.38 / $158.12 / $175.63
| Professional | | $105.38 | $158.12 | $175.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.00 / $177.00 / $415.95
| Professional | | $177.00 | $177.00 | $415.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.45 / $3,728.65 / $3,728.65
| Facility | | $405.45 | $3,728.65 | $3,728.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.36 / $1,328.36 / $2,006.33
| Professional | | $1,328.36 | $1,328.36 | $2,006.33 |