- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.16 / $197.82 / $197.82
| Professional | | $180.16 | $197.82 | $197.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.21 / $1,008.08 / $1,174.58
| Facility | | $596.21 | $1,008.08 | $1,174.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.00 / $221.00 / $370.14
| Professional | | $221.00 | $221.00 | $370.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.60 / $1,242.66 / $2,184.52
| Facility | | $827.60 | $1,242.66 | $2,184.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.22 / $412.19 / $423.74
| Professional | | $230.22 | $412.19 | $423.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.07 / $169.97 / $317.83
| Professional | | $138.07 | $169.97 | $317.83 |