- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $691.83
| Professional | | $407.38 | $575.44 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $2,344.23
| Professional | | $602.56 | $724.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $707.95 / $2,454.71
| Professional | | $478.63 | $707.95 | $2,454.71 |