- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $512.86 / $1,202.26
| Professional | | $501.19 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,288.25 / $1,548.82
| Professional | | $1,148.15 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $794.33 / $1,230.27
| Professional | | $776.25 | $794.33 | $1,230.27 |
- 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
- $758.58 / $977.24 / $2,089.30
| Professional | | $758.58 | $977.24 | $2,089.30 |