- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $776.25 / $1,995.26
| Professional | | $436.52 | $776.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,715.35
| Facility | | $1,659.59 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $371.54 / $812.83
| Professional | | $338.84 | $371.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,737.80 / $4,168.69
| Professional | | $380.19 | $1,737.80 | $4,168.69 |