- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $478.63 / $851.14
| Professional | | $426.58 | $478.63 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $1,659.59
| Professional | | $1,096.48 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $1,348.96
| Professional | | $501.19 | $831.76 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $5,370.32
| Facility | | $1,288.25 | $1,584.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $831.76 / $1,659.59
| Professional | | $489.78 | $831.76 | $1,659.59 |