- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,148.15 / $2,691.53
| Professional | | $446.68 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $3,162.28
| Professional | | $1,698.24 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,258.93
| Professional | | $630.96 | $851.14 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $10,471.29
| Facility | | $1,995.26 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,122.02 / $2,041.74
| Professional | | $660.69 | $1,122.02 | $2,041.74 |