- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $1,659.59
| Professional | | $691.83 | $758.58 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,137.96
| Professional | | $1,905.46 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,047.13 / $1,737.80
| Professional | | $1,023.29 | $1,047.13 | $1,737.80 |
- 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
- $891.25 / $1,348.96 / $2,754.23
| Professional | | $891.25 | $1,348.96 | $2,754.23 |