- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.85 / $471.54 / $1,870.36
| Professional | | $423.85 | $471.54 | $1,870.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.04 / $3,185.89 / $6,926.75
| Facility | | $727.04 | $3,185.89 | $6,926.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.64 / $380.45 / $380.45
| Professional | | $78.64 | $380.45 | $380.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.13 / $1,981.08 / $3,482.61
| Facility | | $1,035.13 | $1,981.08 | $3,482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.53 / $384.75 / $567.80
| Professional | | $233.53 | $384.75 | $567.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.89 / $1,672.75 / $4,452.22
| Professional | | $249.89 | $1,672.75 | $4,452.22 |