- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $933.25 / $2,041.74
| Professional | | $851.14 | $933.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,344.23 / $2,818.38
| Professional | | $1,584.89 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,905.46
| Professional | | $1,047.13 | $1,479.11 | $1,905.46 |
- 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
- $933.25 / $1,698.24 / $2,818.38
| Professional | | $933.25 | $1,698.24 | $2,818.38 |