- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $676.08 / $851.14
| Professional | | $371.54 | $676.08 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $724.44 / $2,691.53
| Professional | | $436.52 | $724.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $741.31 / $2,884.03
| Professional | | $346.74 | $741.31 | $2,884.03 |