- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.74 / $136.34 / $287.29
| Professional | | $104.74 | $136.34 | $287.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.20 / $172.21 / $237.59
| Facility | | $46.20 | $172.21 | $237.59 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.00 / $204.00 / $204.00
| Facility | | $204.00 | $204.00 | $204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.66 / $203.43 / $210.00
| Professional | | $112.66 | $203.43 | $210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.15 / $171.74 / $174.61
| Professional | | $58.15 | $171.74 | $174.61 |