- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.05 / $688.61 / $989.10
| Professional | | $361.05 | $688.61 | $989.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,459.06 / $2,459.06 / $2,656.63
| Facility | | $2,459.06 | $2,459.06 | $2,656.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.11 / $1,347.84 / $4,457.01
| Professional | | $1,110.11 | $1,347.84 | $4,457.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.19 / $740.14 / $1,966.20
| Professional | | $379.19 | $740.14 | $1,966.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.59 / $905.86 / $1,966.20
| Professional | | $508.59 | $905.86 | $1,966.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.55 / $940.02 / $2,746.41
| Professional | | $708.55 | $940.02 | $2,746.41 |