- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.54 / $1,826.23 / $1,826.23
| Professional | | $330.54 | $1,826.23 | $1,826.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.13 / $545.58 / $1,535.69
| Facility | | $404.13 | $545.58 | $1,535.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.58 / $454.82 / $885.30
| Professional | | $253.58 | $454.82 | $885.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.13 / $545.58 / $1,535.69
| Facility | | $404.13 | $545.58 | $1,535.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.02 / $407.43 / $547.05
| Professional | | $282.02 | $407.43 | $547.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.56 / $282.70 / $611.83
| Professional | | $270.56 | $282.70 | $611.83 |