- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.18 / $276.57 / $379.87
| Professional | | $105.18 | $276.57 | $379.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.15 / $2,851.15 / $3,184.11
| Facility | | $2,851.15 | $2,851.15 | $3,184.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.68 / $390.97 / $795.45
| Professional | | $331.68 | $390.97 | $795.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.22 / $299.26 / $795.45
| Professional | | $107.22 | $299.26 | $795.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.41 / $336.71 / $795.45
| Professional | | $120.41 | $336.71 | $795.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.83 / $325.20 / $976.32
| Professional | | $235.83 | $325.20 | $976.32 |