- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,318.26 / $2,951.21
| Professional | | $323.59 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $977.24 / $3,235.94
| Professional | | $851.14 | $977.24 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $2,818.38
| Professional | | $426.58 | $724.44 | $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
- $478.63 / $1,258.93 / $4,168.69
| Professional | | $478.63 | $1,258.93 | $4,168.69 |