- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.25 / $240.30 / $964.54
| Professional | | $168.25 | $240.30 | $964.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,070.11 / $3,070.11 / $3,752.50
| Facility | | $3,070.11 | $3,070.11 | $3,752.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.02 / $1,036.17 / $2,199.10
| Professional | | $879.02 | $1,036.17 | $2,199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.77 / $486.76 / $2,199.10
| Professional | | $241.77 | $486.76 | $2,199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.79 / $849.70 / $2,199.10
| Professional | | $253.79 | $849.70 | $2,199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.19 / $845.04 / $2,699.15
| Professional | | $243.19 | $845.04 | $2,699.15 |