- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $933.25 / $2,238.72
| Professional | | $912.01 | $933.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,884.03
| Professional | | $2,137.96 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,348.96 / $2,187.76
| Professional | | $1,318.26 | $1,348.96 | $2,187.76 |
- 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
- $1,288.25 / $1,778.28 / $3,548.13
| Professional | | $1,288.25 | $1,778.28 | $3,548.13 |