- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $263.03 / $741.31
| Professional | | $151.36 | $263.03 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,511.89
| Facility | | $2,290.87 | $2,290.87 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $398.11 / $1,096.48
| Professional | | $269.15 | $398.11 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $501.19 / $501.19
| Professional | | $316.23 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $331.13 / $691.83
| Professional | | $218.78 | $331.13 | $691.83 |