- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $100.00 / $239.88
| Professional | | $75.86 | $100.00 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $1,023.29
| Facility | | $616.60 | $758.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $123.03 / $218.78
| Professional | | $91.20 | $123.03 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,288.25 / $2,290.87
| Facility | | $436.52 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $173.78 / $239.88
| Professional | | $85.11 | $173.78 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $123.03 / $190.55
| Professional | | $95.50 | $123.03 | $190.55 |