- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $691.83 / $954.99
| Professional | | $616.60 | $691.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $3,388.44
| Professional | | $1,819.70 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,148.15 / $2,041.74
| Professional | | $707.95 | $1,148.15 | $2,041.74 |
- 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
- $724.44 / $1,174.90 / $2,344.23
| Professional | | $724.44 | $1,174.90 | $2,344.23 |