- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $1,513.56
| Professional | | $588.84 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $1,949.84
| Professional | | $1,096.48 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,318.26
| Professional | | $724.44 | $1,023.29 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,168.69 / $14,125.38
| Facility | | $2,691.53 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,174.90 / $1,949.84
| Professional | | $645.65 | $1,174.90 | $1,949.84 |