- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $426.58 / $1,023.29
| Professional | | $354.81 | $426.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $2,187.76
| Professional | | $1,258.93 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $870.96
| Professional | | $457.09 | $602.56 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $5,370.32
| Facility | | $831.76 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $794.33 / $1,445.44
| Professional | | $446.68 | $794.33 | $1,445.44 |