- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $1,122.02
| Professional | | $812.83 | $891.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,570.40
| Professional | | $1,905.46 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,318.26 / $2,238.72
| Professional | | $426.58 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $295.12 / $3,090.30
| Facility | | $281.84 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $707.95 / $1,318.26
| Professional | | $457.09 | $707.95 | $1,318.26 |