- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $426.58 / $776.25
| Professional | | $257.04 | $426.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,659.59 / $2,137.96
| Professional | | $1,047.13 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $870.96
| Professional | | $389.05 | $562.34 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $10,471.29
| Facility | | $1,995.26 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,412.54
| Professional | | $467.74 | $758.58 | $1,412.54 |