- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $562.34 / $1,096.48
| Professional | | $380.19 | $562.34 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $2,818.38
| Professional | | $1,548.82 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $1,148.15
| Professional | | $588.84 | $794.33 | $1,148.15 |
- 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
- $616.60 / $1,023.29 / $1,819.70
| Professional | | $616.60 | $1,023.29 | $1,819.70 |