- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $173.78 / $398.11
| Professional | | $134.90 | $173.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $302.00 / $380.19
| Professional | | $213.80 | $302.00 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $208.93 / $295.12
| Professional | | $158.49 | $208.93 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $338.84 / $3,090.30
| Facility | | $295.12 | $338.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $251.19 / $457.09
| Professional | | $154.88 | $251.19 | $457.09 |