- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $204.17 / $309.03
| Professional | | $75.86 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $407.38 / $1,174.90
| Professional | | $218.78 | $407.38 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $263.03 / $588.84
| Professional | | $93.33 | $263.03 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,288.25 / $5,370.32
| Facility | | $776.25 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $269.15 / $602.56
| Professional | | $102.33 | $269.15 | $602.56 |