- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,344.23
| Professional | | $912.01 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,019.95
| Professional | | $2,187.76 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $2,290.87
| Professional | | $1,348.96 | $1,412.54 | $2,290.87 |
- 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
- $1,348.96 / $1,862.09 / $3,715.35
| Professional | | $1,348.96 | $1,862.09 | $3,715.35 |