- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.91 / $2,005.10 / $2,005.10
| Professional | | $354.91 | $2,005.10 | $2,005.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $476.67 / $601.90 / $1,811.35
| Facility | | $476.67 | $601.90 | $1,811.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.32 / $486.89 / $949.38
| Professional | | $176.32 | $486.89 | $949.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $476.67 / $601.90 / $1,811.35
| Facility | | $476.67 | $601.90 | $1,811.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.23 / $437.68 / $592.33
| Professional | | $303.23 | $437.68 | $592.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.48 / $300.69 / $612.26
| Professional | | $249.48 | $300.69 | $612.26 |