- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $67.61 / $81.28
| Professional | | $57.54 | $67.61 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,230.27
| Facility | | $630.96 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $35.48 / $41.69
| Professional | | $30.90 | $35.48 | $41.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $1,230.27 / $2,187.76
| Facility | | $245.47 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $158.49
| Professional | | $85.11 | $151.36 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $109.65 / $151.36
| Professional | | $64.57 | $109.65 | $151.36 |