- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.23 / $119.81 / $481.00
| Professional | | $98.23 | $119.81 | $481.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.79 / $1,513.79 / $1,938.73
| Facility | | $1,513.79 | $1,513.79 | $1,938.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.72 / $126.50 / $352.15
| Professional | | $100.72 | $126.50 | $352.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.72 / $140.46 / $352.15
| Professional | | $100.72 | $140.46 | $352.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.05 / $143.91 / $432.23
| Professional | | $132.05 | $143.91 | $432.23 |