- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.06 / $280.38 / $416.73
| Professional | | $191.06 | $280.38 | $416.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.12 / $2,851.12 / $3,140.17
| Facility | | $2,851.12 | $2,851.12 | $3,140.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.08 / $396.10 / $1,075.44
| Professional | | $266.08 | $396.10 | $1,075.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $423.17 / $1,075.44
| Professional | | $271.60 | $423.17 | $1,075.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.06 / $355.32 / $1,215.10
| Professional | | $303.06 | $355.32 | $1,215.10 |