- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.31 / $1,035.04 / $1,035.04
| Professional | | $211.31 | $1,035.04 | $1,035.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.26 / $321.26 / $321.26
| Facility | | $321.26 | $321.26 | $321.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.81 / $321.26 / $321.26
| Professional | | $211.81 | $321.26 | $321.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.30 / $335.40 / $353.57
| Facility | | $157.30 | $335.40 | $353.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.39 / $293.12 / $422.80
| Professional | | $195.39 | $293.12 | $422.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.43 / $335.39 / $563.32
| Professional | | $267.43 | $335.39 | $563.32 |