- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $2,951.21
| Professional | | $389.05 | $1,230.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $3,162.28
| Professional | | $1,071.52 | $1,202.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $794.33 / $2,290.87
| Professional | | $467.74 | $794.33 | $2,290.87 |
- 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
- $524.81 / $1,412.54 / $3,801.89
| Professional | | $524.81 | $1,412.54 | $3,801.89 |