- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $1,380.38
| Professional | | $457.09 | $602.56 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $3,162.28
| Professional | | $1,949.84 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $724.44 / $1,047.13
| Professional | | $537.03 | $724.44 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $10,471.29
| Facility | | $1,949.84 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $977.24 / $1,659.59
| Professional | | $524.81 | $977.24 | $1,659.59 |