- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.58 / $241.33 / $508.51
| Professional | | $190.58 | $241.33 | $508.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.01 / $158.00 / $284.58
| Facility | | $73.01 | $158.00 | $284.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.40 / $144.30 / $503.60
| Professional | | $27.40 | $144.30 | $503.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,922.50 / $2,922.50
| Facility | | $55.00 | $2,922.50 | $2,922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $1,397.77 / $1,397.77
| Professional | | $816.00 | $1,397.77 | $1,397.77 |