- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.69 / $2,156.48 / $2,156.48
| Professional | | $385.69 | $2,156.48 | $2,156.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.30 / $570.15 / $1,911.67
| Facility | | $486.30 | $570.15 | $1,911.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.30 / $486.30 / $486.30
| Professional | | $486.30 | $486.30 | $486.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.30 / $570.15 / $1,911.67
| Facility | | $486.30 | $570.15 | $1,911.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.83 / $301.83 / $486.30
| Professional | | $301.83 | $301.83 | $486.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.86 / $140.86 / $335.38
| Professional | | $140.86 | $140.86 | $335.38 |