- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $489.78 / $1,174.90
| Professional | | $478.63 | $489.78 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $1,479.11
| Professional | | $1,096.48 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $724.44 / $1,174.90
| Professional | | $691.83 | $724.44 | $1,174.90 |
- 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
- $676.08 / $933.25 / $1,862.09
| Professional | | $676.08 | $933.25 | $1,862.09 |