- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,479.11 / $2,951.21
| Professional | | $323.59 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $3,715.35
| Professional | | $912.01 | $1,047.13 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $741.31 / $2,818.38
| Professional | | $416.87 | $741.31 | $2,818.38 |
- 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
- $467.74 / $1,202.26 / $3,890.45
| Professional | | $467.74 | $1,202.26 | $3,890.45 |