- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.33 / $690.47 / $1,059.86
| Professional | | $474.33 | $690.47 | $1,059.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.90 / $360.90 / $360.90
| Facility | | $360.90 | $360.90 | $360.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.77 / $360.90 / $1,233.75
| Professional | | $306.77 | $360.90 | $1,233.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,422.50 / $2,422.50 / $2,422.50
| Professional | | $2,422.50 | $2,422.50 | $2,422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.75 / $1,096.18 / $1,152.33
| Professional | | $931.75 | $1,096.18 | $1,152.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.86 / $822.13 / $1,247.64
| Professional | | $607.86 | $822.13 | $1,247.64 |