- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.28 / $338.51 / $1,619.74
| Professional | | $241.28 | $338.51 | $1,619.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.85 / $1,198.85 / $1,535.38
| Facility | | $1,198.85 | $1,198.85 | $1,535.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.90 / $376.15 / $1,063.97
| Professional | | $218.90 | $376.15 | $1,063.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.58 / $450.43 / $1,063.97
| Professional | | $308.58 | $450.43 | $1,063.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.50 / $430.82 / $1,305.90
| Professional | | $338.50 | $430.82 | $1,305.90 |