- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.86 / $240.42 / $468.75
| Professional | | $180.86 | $240.42 | $468.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,837.72 / $3,837.72 / $4,915.00
| Facility | | $3,837.72 | $3,837.72 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.29 / $336.88 / $938.52
| Professional | | $244.29 | $336.88 | $938.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.95 / $369.38 / $938.52
| Professional | | $255.95 | $369.38 | $938.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.23 / $360.30 / $1,047.43
| Professional | | $270.23 | $360.30 | $1,047.43 |