- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.19 / $658.09 / $957.88
| Professional | | $385.19 | $658.09 | $957.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.88 / $79.26 / $663.22
| Professional | | $37.88 | $79.26 | $663.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.72 / $1,156.68 / $2,041.20
| Facility | | $90.72 | $1,156.68 | $2,041.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.53 / $1,227.53 / $1,227.53
| Professional | | $1,227.53 | $1,227.53 | $1,227.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.92 / $743.81 / $1,053.90
| Professional | | $68.92 | $743.81 | $1,053.90 |