- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $1,380.38
| Professional | | $616.60 | $724.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $1,778.28
| Professional | | $1,548.82 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,445.44
| Professional | | $870.96 | $870.96 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,168.69 / $14,125.38
| Facility | | $2,691.53 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,290.87
| Professional | | $758.58 | $1,174.90 | $2,290.87 |