- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $151.36 / $269.15
| Professional | | $138.04 | $151.36 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $446.68 / $446.68
| Professional | | $295.12 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $263.03 / $436.52
| Professional | | $154.88 | $263.03 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $3,090.30
| Facility | | $204.17 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $263.03 / $537.03
| Professional | | $151.36 | $263.03 | $537.03 |