- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $549.54
| Professional | | $288.40 | $416.87 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $1,905.46
| Professional | | $812.83 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $537.03 / $1,122.02
| Professional | | $323.59 | $537.03 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $616.60 / $1,096.48
| Professional | | $371.54 | $616.60 | $1,096.48 |