- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.77 / $136.09 / $144.00
| Professional | | $118.77 | $136.09 | $144.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.22 / $173.20 / $298.02
| Professional | | $147.22 | $173.20 | $298.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Facility | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $238.16
| Professional | | $202.44 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.69 / $188.21 / $342.54
| Professional | | $126.69 | $188.21 | $342.54 |