- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $524.81 / $912.01
| Professional | | $478.63 | $524.81 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,698.24 / $2,041.74
| Professional | | $1,047.13 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,318.26
| Professional | | $602.56 | $954.99 | $1,318.26 |
- 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
- $524.81 / $933.25 / $1,949.84
| Professional | | $524.81 | $933.25 | $1,949.84 |