- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $2,238.72
| Professional | | $691.83 | $977.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,128.61 / $5,128.61
| Professional | | $3,162.28 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,548.82
| Professional | | $794.33 | $1,071.52 | $1,548.82 |
- 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
- $812.83 / $1,584.89 / $2,570.40
| Professional | | $812.83 | $1,584.89 | $2,570.40 |