- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $239.88 / $269.15
| Professional | | $97.72 | $239.88 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $251.19 / $1,000.00
| Professional | | $199.53 | $251.19 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $269.15
| Professional | | $114.82 | $114.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $309.03 / $446.68
| Professional | | $245.47 | $309.03 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $134.90 / $204.17
| Professional | | $100.00 | $134.90 | $204.17 |