- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $1,479.11
| Professional | | $30.20 | $47.86 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $38.90 / $52.48
| Facility | | $33.11 | $38.90 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,348.96
| Professional | | $707.95 | $977.24 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $50.12 / $70.79
| Professional | | $43.65 | $50.12 | $70.79 |