- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $912.01 / $2,137.96
| Professional | | $741.31 | $912.01 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $4,897.79
| Professional | | $3,019.95 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,698.24
| Professional | | $870.96 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,467.37 / $10,471.29
| Facility | | $2,630.27 | $3,467.37 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,513.56 / $2,691.53
| Professional | | $870.96 | $1,513.56 | $2,691.53 |