- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $912.01 / $2,344.23
| Professional | | $891.25 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $2,754.23
| Professional | | $2,238.72 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $2,238.72
| Professional | | $1,288.25 | $1,584.89 | $2,238.72 |
- 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
- $1,148.15 / $1,819.70 / $3,548.13
| Professional | | $1,148.15 | $1,819.70 | $3,548.13 |