- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.07 / $1,040.04 / $1,040.04
| Professional | | $137.07 | $1,040.04 | $1,040.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.84 / $207.29 / $274.66
| Professional | | $118.84 | $207.29 | $274.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.73 / $510.58 / $686.89
| Facility | | $420.73 | $510.58 | $686.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.32 / $207.29 / $244.60
| Professional | | $151.32 | $207.29 | $244.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.95 / $347.23 / $567.89
| Professional | | $280.95 | $347.23 | $567.89 |