- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.60 / $129.58 / $129.58
| Facility | | $83.60 | $129.58 | $129.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.87 / $129.58 / $139.33
| Professional | | $82.87 | $129.58 | $139.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.00 / $161.00 / $378.35
| Professional | | $161.00 | $161.00 | $378.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.65 / $2,141.75 / $2,141.75
| Facility | | $242.65 | $2,141.75 | $2,141.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.69 / $887.69 / $1,145.03
| Professional | | $887.69 | $887.69 | $1,145.03 |