- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.56 / $146.57 / $335.77
| Professional | | $27.56 | $146.57 | $335.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.25 / $3,206.25 / $3,206.25
| Facility | | $3,206.25 | $3,206.25 | $3,206.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,206.25 / $3,206.25 / $3,206.25
| Professional | | $3,206.25 | $3,206.25 | $3,206.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.36 / $272.33 / $535.57
| Facility | | $233.36 | $272.33 | $535.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $40.00
| Professional | | $17.00 | $20.00 | $40.00 |