- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $125.89 / $309.03
| Professional | | $112.20 | $125.89 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $331.13 / $398.11
| Professional | | $223.87 | $331.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $309.03
| Professional | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $3,235.94
| Facility | | $794.33 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $239.88 / $512.86
| Professional | | $158.49 | $239.88 | $512.86 |