- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.81 / $1,165.53 / $2,439.88
| Professional | | $230.81 | $1,165.53 | $2,439.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.01 / $523.48 / $1,283.53
| Facility | | $282.01 | $523.48 | $1,283.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $3,174.88 / $3,174.88
| Professional | | $952.00 | $3,174.88 | $3,174.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.00 / $970.00 / $970.00
| Facility | | $970.00 | $970.00 | $970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.57 / $981.31 / $1,091.05
| Professional | | $162.57 | $981.31 | $1,091.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $451.40 / $1,443.50
| Professional | | $4.00 | $451.40 | $1,443.50 |