- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,120.75 / $1,568.09
| Professional | | $731.78 | $1,120.75 | $1,568.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.82 / $1,590.82 / $1,910.52
| Professional | | $1,590.82 | $1,590.82 | $1,910.52 |
- 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 / $1,221.04 / $3,759.38
| Professional | | $183.43 | $1,221.04 | $3,759.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.52 / $259.52 / $259.52
| Professional | | $259.52 | $259.52 | $259.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.99 / $1,092.43 / $1,485.94
| Professional | | $875.99 | $1,092.43 | $1,485.94 |