- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.53 / $268.55 / $487.63
| Professional | | $187.53 | $268.55 | $487.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,312.51 / $3,312.51 / $4,242.35
| Facility | | $3,312.51 | $3,312.51 | $4,242.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.65 / $385.51 / $942.60
| Professional | | $254.65 | $385.51 | $942.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.16 / $386.64 / $942.60
| Professional | | $265.16 | $386.64 | $942.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.95 / $348.01 / $1,120.04
| Professional | | $288.95 | $348.01 | $1,120.04 |