- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $213.80 / $302.00
| Professional | | $120.23 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $389.05 / $575.44
| Professional | | $218.78 | $389.05 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $263.03 / $426.58
| Professional | | $158.49 | $263.03 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,162.28 / $5,370.32
| Facility | | $1,288.25 | $3,162.28 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $363.08 / $660.69
| Professional | | $177.83 | $363.08 | $660.69 |