- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $263.03 / $309.03
| Professional | | $107.15 | $263.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $331.13 / $758.58
| Professional | | $190.55 | $331.13 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $524.81
| Professional | | $147.91 | $251.19 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $331.13 / $3,090.30
| Facility | | $295.12 | $331.13 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $416.87 / $831.76
| Professional | | $165.96 | $416.87 | $831.76 |