- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $1,659.59
| Professional | | $776.25 | $954.99 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $2,630.27
| Professional | | $1,659.59 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,819.70
| Professional | | $812.83 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,168.69 / $14,125.38
| Facility | | $3,162.28 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,584.89 / $2,818.38
| Professional | | $891.25 | $1,584.89 | $2,818.38 |