- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $537.03 / $912.01
| Professional | | $91.20 | $537.03 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $288.40 / $1,737.80
| Professional | | $213.80 | $288.40 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $398.11 / $1,479.11
| Professional | | $97.72 | $398.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $5,370.32
| Facility | | $1,288.25 | $1,412.54 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $457.09 / $1,412.54
| Professional | | $114.82 | $457.09 | $1,412.54 |