- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $501.19
| Professional | | $398.11 | $398.11 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $426.58 / $501.19
| Professional | | $151.36 | $426.58 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $12,022.64
| Facility | | $323.59 | $323.59 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $457.09 / $1,412.54
| Professional | | $269.15 | $457.09 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $338.84 / $407.38
| Professional | | $6.03 | $338.84 | $407.38 |