- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $616.60 / $1,513.56
| Professional | | $537.03 | $616.60 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $1,905.46
| Professional | | $1,096.48 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,548.82
| Professional | | $812.83 | $1,000.00 | $1,548.82 |
- 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
- $707.95 / $1,148.15 / $2,187.76
| Professional | | $707.95 | $1,148.15 | $2,187.76 |