- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,949.84
| Professional | | $676.08 | $851.14 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $2,041.74
| Professional | | $1,258.93 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,548.82
| Professional | | $812.83 | $1,071.52 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $5,370.32
| Facility | | $1,288.25 | $1,584.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,511.89
| Professional | | $851.14 | $1,258.93 | $2,511.89 |