- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,400.77 / $2,045.34
| Professional | | $731.78 | $1,400.77 | $2,045.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.19 / $2,054.19 / $2,054.19
| Professional | | $2,054.19 | $2,054.19 | $2,054.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $3,759.38
| Professional | | $183.43 | $1,436.52 | $3,759.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.29 / $1,090.25 / $1,729.68
| Professional | | $728.29 | $1,090.25 | $1,729.68 |