- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $91.20 / $131.83
| Professional | | $91.20 | $91.20 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $707.95 / $1,096.48
| Facility | | $363.08 | $707.95 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $138.04 / $346.74
| Professional | | $56.23 | $138.04 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,388.44 / $3,388.44
| Facility | | $758.58 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,691.53
| Professional | | $1,862.09 | $1,862.09 | $2,691.53 |