- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.89 / $203.30 / $321.05
| Professional | | $124.89 | $203.30 | $321.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,712.82 / $2,712.82 / $3,394.81
| Facility | | $2,712.82 | $2,712.82 | $3,394.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.29 / $322.92 / $782.25
| Professional | | $141.29 | $322.92 | $782.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.29 / $322.92 / $782.25
| Professional | | $141.29 | $322.92 | $782.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.13 / $337.47 / $960.12
| Professional | | $288.13 | $337.47 | $960.12 |