- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $263.03 / $389.05
| Professional | | $95.50 | $263.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $457.09
| Professional | | $204.17 | $302.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $190.55 / $288.40
| Professional | | $147.91 | $190.55 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $295.12 / $3,090.30
| Facility | | $263.03 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $275.42 / $478.63
| Professional | | $162.18 | $275.42 | $478.63 |