- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $776.25 / $1,737.80
| Professional | | $676.08 | $776.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,238.72
| Professional | | $1,288.25 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,174.90 / $1,659.59
| Professional | | $977.24 | $1,174.90 | $1,659.59 |
- 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
- $870.96 / $1,380.38 / $2,630.27
| Professional | | $870.96 | $1,380.38 | $2,630.27 |