- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $933.25 / $2,454.71
| Professional | | $912.01 | $933.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,884.03
| Professional | | $1,905.46 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,398.83
| Professional | | $1,318.26 | $1,659.59 | $2,398.83 |
- 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
- $1,202.26 / $1,905.46 / $3,715.35
| Professional | | $1,202.26 | $1,905.46 | $3,715.35 |