- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $707.95 / $1,737.80
| Professional | | $616.60 | $707.95 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $2,187.76
| Professional | | $1,479.11 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $1,698.24
| Professional | | $912.01 | $1,148.15 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $10,471.29
| Facility | | $1,737.80 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,511.89
| Professional | | $831.76 | $1,348.96 | $2,511.89 |