- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $660.69 / $1,659.59
| Professional | | $588.84 | $660.69 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,238.72
| Professional | | $1,258.93 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,479.11
| Professional | | $851.14 | $1,122.02 | $1,479.11 |
- 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
- $724.44 / $1,288.25 / $2,238.72
| Professional | | $724.44 | $1,288.25 | $2,238.72 |