- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $831.76
| Professional | | $549.54 | $616.60 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $2,951.21
| Professional | | $1,621.81 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $977.24 / $1,737.80
| Professional | | $630.96 | $977.24 | $1,737.80 |
- 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
- $630.96 / $1,023.29 / $1,949.84
| Professional | | $630.96 | $1,023.29 | $1,949.84 |