- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.29 / $135.37 / $427.53
| Professional | | $108.29 | $135.37 | $427.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.41 / $537.41 / $2,922.50
| Facility | | $537.41 | $537.41 | $2,922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.09 / $2,380.44 / $2,380.44
| Professional | | $771.09 | $2,380.44 | $2,380.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.31 / $232.39 / $308.00
| Facility | | $179.31 | $232.39 | $308.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.31 / $301.00 / $788.00
| Professional | | $179.31 | $301.00 | $788.00 |