- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.62 / $232.28 / $893.71
| Professional | | $177.62 | $232.28 | $893.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,403.04 / $3,403.04 / $3,800.45
| Facility | | $3,403.04 | $3,403.04 | $3,800.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.34 / $650.34 / $1,660.22
| Professional | | $650.34 | $650.34 | $1,660.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.62 / $387.60 / $1,660.22
| Professional | | $241.62 | $387.60 | $1,660.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.60 / $645.62 / $1,660.22
| Professional | | $245.60 | $645.62 | $1,660.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.88 / $618.30 / $1,797.47
| Professional | | $248.88 | $618.30 | $1,797.47 |