- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $891.25 / $2,344.23
| Professional | | $870.96 | $891.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $2,754.23
| Professional | | $2,187.76 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,187.76
| Professional | | $1,258.93 | $1,548.82 | $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
- $1,122.02 / $1,819.70 / $3,467.37
| Professional | | $1,122.02 | $1,819.70 | $3,467.37 |