- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $191.80 / $813.96
| Professional | | $172.18 | $191.80 | $813.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.38 / $2,000.38 / $2,561.89
| Facility | | $2,000.38 | $2,000.38 | $2,561.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.49 / $922.37 / $2,175.08
| Professional | | $782.49 | $922.37 | $2,175.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.13 / $401.76 / $1,549.85
| Professional | | $221.13 | $401.76 | $1,549.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.84 / $306.87 / $1,492.94
| Professional | | $222.84 | $306.87 | $1,492.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.11 / $958.75 / $2,669.67
| Professional | | $608.11 | $958.75 | $2,669.67 |