- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,778.28
| Professional | | $630.96 | $707.95 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $2,398.83
| Professional | | $1,348.96 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,737.80
| Professional | | $933.25 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $14,125.38
| Facility | | $4,168.69 | $6,309.57 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,454.71
| Professional | | $812.83 | $1,412.54 | $2,454.71 |