- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,148.15
| Professional | | $630.96 | $831.76 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,230.27 / $1,230.27
| Professional | | $125.89 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,023.29
| Professional | | $478.63 | $741.31 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $371.54 / $891.25
| Facility | | $56.23 | $371.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $954.99
| Professional | | $478.63 | $602.56 | $954.99 |