- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $549.54 / $1,445.44
| Professional | | $537.03 | $549.54 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $1,698.24
| Professional | | $1,148.15 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,348.96
| Professional | | $776.25 | $977.24 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $10,471.29
| Facility | | $2,630.27 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $2,137.96
| Professional | | $691.83 | $1,122.02 | $2,137.96 |