- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $380.19 / $512.86
| Professional | | $338.84 | $380.19 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $1,819.70
| Professional | | $977.24 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $616.60 / $1,202.26
| Professional | | $389.05 | $616.60 | $1,202.26 |
- 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
- $416.87 / $660.69 / $1,348.96
| Professional | | $416.87 | $660.69 | $1,348.96 |