- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,778.28
| Professional | | $776.25 | $851.14 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $2,290.87
| Professional | | $1,288.25 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $1,778.28
| Professional | | $977.24 | $1,202.26 | $1,778.28 |
- 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
- $870.96 / $1,380.38 / $2,630.27
| Professional | | $870.96 | $1,380.38 | $2,630.27 |