- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $446.68 / $794.33
| Professional | | $426.58 | $446.68 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $1,737.80
| Professional | | $912.01 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $851.14 / $1,148.15
| Professional | | $562.34 | $851.14 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $5,370.32
| Facility | | $1,288.25 | $1,659.59 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $812.83 / $1,949.84
| Professional | | $512.86 | $812.83 | $1,949.84 |