- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $524.81 / $1,318.26
| Professional | | $446.68 | $524.81 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,318.26
| Professional | | $1,096.48 | $1,096.48 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,174.90
| Professional | | $630.96 | $870.96 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $10,471.29
| Facility | | $2,630.27 | $3,311.31 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,023.29 / $1,659.59
| Professional | | $524.81 | $1,023.29 | $1,659.59 |