- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $1,778.28
| Professional | | $691.83 | $794.33 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $2,344.23
| Professional | | $1,318.26 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,698.24
| Professional | | $954.99 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,570.40
| Professional | | $812.83 | $1,412.54 | $2,570.40 |