- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $1,047.13
| Professional | | $676.08 | $758.58 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,090.30 / $3,715.35
| Professional | | $1,995.26 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,288.25 / $2,398.83
| Professional | | $776.25 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,918.31 / $25,703.96
| Facility | | $5,011.87 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,570.40
| Professional | | $812.83 | $1,288.25 | $2,570.40 |