- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.83 / $778.22 / $795.60
| Professional | | $587.83 | $778.22 | $795.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.30 / $773.30 / $773.30
| Professional | | $773.30 | $773.30 | $773.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.54 / $2,355.54 / $2,355.54
| Facility | | $2,355.54 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.21 / $2,355.54 / $2,355.54
| Professional | | $2,002.21 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.58 / $474.61 / $632.82
| Professional | | $301.58 | $474.61 | $632.82 |