- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.91 / $349.36 / $860.56
| Professional | | $168.91 | $349.36 | $860.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,093.63 / $3,093.63 / $3,291.09
| Facility | | $3,093.63 | $3,093.63 | $3,291.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.06 / $380.04 / $1,335.02
| Professional | | $250.06 | $380.04 | $1,335.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.06 / $426.41 / $1,335.02
| Professional | | $250.06 | $426.41 | $1,335.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.27 / $461.50 / $1,638.59
| Professional | | $308.27 | $461.50 | $1,638.59 |