- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.78 / $320.44 / $1,160.25
| Professional | | $90.78 | $320.44 | $1,160.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,560.65 / $2,560.65 / $3,180.45
| Facility | | $2,560.65 | $2,560.65 | $3,180.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.83 / $465.41 / $1,118.23
| Professional | | $394.83 | $465.41 | $1,118.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.08 / $298.73 / $1,118.23
| Professional | | $135.08 | $298.73 | $1,118.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.69 / $434.35 / $1,118.23
| Professional | | $143.69 | $434.35 | $1,118.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.97 / $447.26 / $1,372.50
| Professional | | $305.97 | $447.26 | $1,372.50 |