- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.93 / $138.51 / $1,340.25
| Professional | | $94.93 | $138.51 | $1,340.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.04 / $1,987.04 / $2,467.98
| Facility | | $1,987.04 | $1,987.04 | $2,467.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.45 / $561.62 / $1,759.01
| Professional | | $476.45 | $561.62 | $1,759.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.44 / $303.88 / $1,165.08
| Professional | | $156.44 | $303.88 | $1,165.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.41 / $402.69 / $1,165.08
| Professional | | $182.41 | $402.69 | $1,165.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.16 / $983.10 / $1,430.01
| Professional | | $422.16 | $983.10 | $1,430.01 |