- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $199.53 / $263.03
| Professional | | $123.03 | $199.53 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $263.03 / $295.12
| Professional | | $199.53 | $263.03 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $295.12 / $354.81
| Professional | | $275.42 | $295.12 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $346.74
| Facility | | $199.53 | $199.53 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $100.00 / $1,584.89
| Professional | | $79.43 | $100.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $190.55
| Professional | | $93.33 | $93.33 | $190.55 |