- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $676.08 / $2,511.89
| Professional | | $363.08 | $676.08 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,089.30
| Professional | | $1,230.27 | $1,995.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $575.44 / $851.14
| Professional | | $446.68 | $575.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $10,471.29
| Facility | | $1,995.26 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $776.25 / $1,445.44
| Professional | | $436.52 | $776.25 | $1,445.44 |