- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $331.13 / $851.14
| Professional | | $295.12 | $331.13 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $1,148.15
| Professional | | $776.25 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $758.58
| Professional | | $407.38 | $575.44 | $758.58 |
- 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
- $363.08 / $660.69 / $1,096.48
| Professional | | $363.08 | $660.69 | $1,096.48 |