- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $1,584.89
| Professional | | $758.58 | $933.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,570.40
| Professional | | $1,584.89 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $1,778.28
| Professional | | $741.31 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $10,471.29
| Facility | | $2,454.71 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $2,754.23
| Professional | | $870.96 | $1,548.82 | $2,754.23 |