- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $776.25
| Professional | | $501.19 | $575.44 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,290.87 / $2,754.23
| Professional | | $1,479.11 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $954.99 / $1,659.59
| Professional | | $575.44 | $954.99 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $5,370.32
| Facility | | $1,258.93 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $933.25 / $1,819.70
| Professional | | $588.84 | $933.25 | $1,819.70 |