- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $269.15 / $933.25
| Professional | | $147.91 | $269.15 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,388.44
| Facility | | $2,630.27 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $389.05 / $954.99
| Professional | | $257.04 | $389.05 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $436.52 / $436.52
| Professional | | $288.40 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $660.69
| Professional | | $213.80 | $316.23 | $660.69 |