- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $676.08 / $912.01
| Professional | | $575.44 | $676.08 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,691.53 / $3,235.94
| Professional | | $1,737.80 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $1,905.46
| Professional | | $691.83 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $14,125.38
| Facility | | $3,019.95 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $2,187.76
| Professional | | $691.83 | $1,122.02 | $2,187.76 |