- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.78 / $283.56 / $1,103.36
| Professional | | $106.78 | $283.56 | $1,103.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,272.85 / $4,272.85 / $5,307.10
| Facility | | $4,272.85 | $4,272.85 | $5,307.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.33 / $343.87 / $737.52
| Professional | | $214.33 | $343.87 | $737.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $346.92 / $737.52
| Professional | | $225.69 | $346.92 | $737.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.06 / $297.74 / $905.22
| Professional | | $275.06 | $297.74 | $905.22 |