- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.03 / $978.74 / $978.74
| Professional | | $657.03 | $978.74 | $978.74 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $101.49 / $558.48 / $1,094.83
| Facility | | $101.49 | $558.48 | $1,094.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.98 / $1,586.78 / $5,878.81
| Professional | | $842.98 | $1,586.78 | $5,878.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.44 / $842.98 / $1,939.28
| Professional | | $408.44 | $842.98 | $1,939.28 |