- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.10 / $144.19 / $223.16
| Professional | | $133.10 | $144.19 | $223.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.43 / $1,960.43 / $2,189.36
| Facility | | $1,960.43 | $1,960.43 | $2,189.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.66 / $223.38 / $435.62
| Professional | | $154.66 | $223.38 | $435.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.16 / $247.28 / $435.62
| Professional | | $163.16 | $247.28 | $435.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.74 / $273.60 / $452.19
| Professional | | $224.74 | $273.60 | $452.19 |