- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $660.69 / $977.24
| Professional | | $537.03 | $660.69 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $1,862.09
| Professional | | $1,047.13 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $1,949.84
| Professional | | $776.25 | $1,174.90 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $2,570.40
| Professional | | $724.44 | $1,148.15 | $2,570.40 |