- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $851.14
| Professional | | $575.44 | $630.96 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $3,019.95
| Professional | | $1,659.59 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,047.13 / $1,949.84
| Professional | | $630.96 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $2,137.96
| Professional | | $676.08 | $1,071.52 | $2,137.96 |