- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $954.99 / $2,290.87
| Professional | | $354.81 | $954.99 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,318.26 / $2,630.27
| Professional | | $758.58 | $1,318.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $776.25 / $1,737.80
| Professional | | $407.38 | $776.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,754.23 / $5,370.32
| Facility | | $1,288.25 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,122.02 / $2,754.23
| Professional | | $478.63 | $1,122.02 | $2,754.23 |