- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $2,344.23
| Professional | | $691.83 | $870.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $1,513.56
| Professional | | $645.65 | $851.14 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $1,819.70
| Professional | | $812.83 | $1,412.54 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $1,862.09
| Professional | | $724.44 | $1,122.02 | $1,862.09 |