- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $234.42 / $407.38
| Professional | | $186.21 | $234.42 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $457.09 / $870.96
| Professional | | $407.38 | $457.09 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $575.44
| Professional | | $204.17 | $295.12 | $575.44 |