- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $776.25 / $1,995.26
| Professional | | $758.58 | $776.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,949.84 / $2,344.23
| Professional | | $1,584.89 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $1,819.70
| Professional | | $1,047.13 | $1,348.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $10,471.29
| Facility | | $2,630.27 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $2,818.38
| Professional | | $933.25 | $1,548.82 | $2,818.38 |