- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,995.26
| Professional | | $630.96 | $707.95 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $1,819.70
| Professional | | $1,258.93 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $1,862.09
| Professional | | $1,047.13 | $1,348.96 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $14,125.38
| Facility | | $4,168.69 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,621.81 / $2,818.38
| Professional | | $933.25 | $1,621.81 | $2,818.38 |