- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.60 / $157.02 / $222.70
| Professional | | $109.60 | $157.02 | $222.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.00 / $417.00 / $644.00
| Professional | | $308.00 | $417.00 | $644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.82 / $216.05 / $368.26
| Professional | | $137.82 | $216.05 | $368.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $2,962.56 / $3,328.00
| Facility | | $788.00 | $2,962.56 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.37 / $280.14 / $637.54
| Professional | | $167.37 | $280.14 | $637.54 |