- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $171.31 / $378.28
| Professional | | $71.84 | $171.31 | $378.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $932.96 / $991.02 / $2,840.07
| Facility | | $932.96 | $991.02 | $2,840.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.52 / $365.77 / $1,061.51
| Professional | | $304.52 | $365.77 | $1,061.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.83 / $249.85 / $1,061.51
| Professional | | $100.83 | $249.85 | $1,061.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.22 / $288.58 / $1,061.51
| Professional | | $113.22 | $288.58 | $1,061.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.00 / $395.51 / $1,302.89
| Professional | | $224.00 | $395.51 | $1,302.89 |