- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $524.81 / $1,122.02
| Professional | | $457.09 | $524.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,445.44
| Professional | | $1,047.13 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $707.95 / $1,122.02
| Professional | | $691.83 | $707.95 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $1,862.09
| Professional | | $676.08 | $891.25 | $1,862.09 |