- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $141.25 / $309.03
| Professional | | $120.23 | $141.25 | $309.03 |
- 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
- $245.47 / $371.54 / $426.58
| Professional | | $245.47 | $371.54 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $251.19 / $416.87
| Professional | | $141.25 | $251.19 | $416.87 |
- 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
- $134.90 / $245.47 / $478.63
| Professional | | $134.90 | $245.47 | $478.63 |