- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.60 / $580.32 / $3,009.24
| Professional | | $327.60 | $580.32 | $3,009.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.32 / $783.32 / $783.32
| Facility | | $783.32 | $783.32 | $783.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.75 / $529.62 / $1,051.70
| Professional | | $222.75 | $529.62 | $1,051.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.32 / $783.32 / $783.32
| Facility | | $783.32 | $783.32 | $783.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.75 / $529.62 / $1,051.70
| Professional | | $222.75 | $529.62 | $1,051.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.42 / $655.20 / $1,081.27
| Professional | | $204.42 | $655.20 | $1,081.27 |