- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.54 / $705.34 / $1,084.89
| Professional | | $491.54 | $705.34 | $1,084.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.83 / $1,100.60 / $1,156.32
| Professional | | $974.83 | $1,100.60 | $1,156.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.04 / $860.04 / $860.04
| Facility | | $860.04 | $860.04 | $860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.91 / $860.04 / $2,081.25
| Professional | | $126.91 | $860.04 | $2,081.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.56 / $179.56 / $179.56
| Professional | | $179.56 | $179.56 | $179.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.29 / $755.72 / $1,008.63
| Professional | | $604.29 | $755.72 | $1,008.63 |