- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.62 / $322.62 / $3,394.20
| Professional | | $322.62 | $322.62 | $3,394.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.53 / $883.53 / $883.53
| Facility | | $883.53 | $883.53 | $883.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.31 / $1,186.31 / $1,186.31
| Professional | | $1,186.31 | $1,186.31 | $1,186.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.53 / $883.53 / $883.53
| Facility | | $883.53 | $883.53 | $883.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.12 / $343.12 / $1,186.31
| Professional | | $343.12 | $343.12 | $1,186.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.57 / $527.87 / $2,375.42
| Professional | | $230.57 | $527.87 | $2,375.42 |