- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.60 / $832.56 / $969.12
| Professional | | $474.60 | $832.56 | $969.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.18 / $1,151.29 / $1,279.21
| Facility | | $883.18 | $1,151.29 | $1,279.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.27 / $813.54 / $2,109.46
| Professional | | $772.27 | $813.54 | $2,109.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.33 / $2,517.94 / $3,040.26
| Facility | | $1,432.33 | $2,517.94 | $3,040.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.44 / $1,402.38 / $2,218.42
| Professional | | $847.44 | $1,402.38 | $2,218.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.59 / $957.17 / $1,323.96
| Professional | | $200.59 | $957.17 | $1,323.96 |