- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $457.09 / $977.24
| Professional | | $398.11 | $457.09 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $1,258.93
| Professional | | $933.25 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $1,047.13
| Professional | | $549.54 | $549.54 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,445.44
| Professional | | $501.19 | $794.33 | $1,445.44 |