- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $263.03 / $3,890.45
| Professional | | $181.97 | $263.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $537.03 / $691.83
| Professional | | $363.08 | $537.03 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $363.08 / $512.86
| Professional | | $269.15 | $363.08 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $10,471.29
| Facility | | $1,737.80 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $467.74 / $831.76
| Professional | | $309.03 | $467.74 | $831.76 |