- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $467.74 / $1,096.48
| Professional | | $457.09 | $467.74 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,412.54
| Professional | | $1,047.13 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $724.44 / $1,122.02
| Professional | | $707.95 | $724.44 | $1,122.02 |
- 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
- $691.83 / $891.25 / $1,905.46
| Professional | | $691.83 | $891.25 | $1,905.46 |