- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.64 / $958.44 / $958.44
| Professional | | $808.64 | $958.44 | $958.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.92 / $244.64 / $478.34
| Facility | | $190.92 | $244.64 | $478.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.21 / $237.21 / $237.21
| Professional | | $237.21 | $237.21 | $237.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,888.44 / $3,008.01 / $3,319.75
| Facility | | $1,888.44 | $3,008.01 | $3,319.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.26 / $1,354.64 / $1,693.30
| Professional | | $547.26 | $1,354.64 | $1,693.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.66 / $1,078.57 / $1,725.71
| Professional | | $394.66 | $1,078.57 | $1,725.71 |