- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $380.19 / $407.38
| Professional | | $354.81 | $380.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,288.25
| Professional | | $870.96 | $1,096.48 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $8,317.64 / $10,471.29
| Facility | | $2,630.27 | $8,317.64 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $851.14 / $1,412.54
| Professional | | $524.81 | $851.14 | $1,412.54 |