- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $851.14 / $2,238.72
| Professional | | $831.76 | $851.14 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $2,630.27
| Professional | | $2,089.30 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,089.30
| Professional | | $1,202.26 | $1,479.11 | $2,089.30 |
- 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
- $1,071.52 / $1,737.80 / $3,311.31
| Professional | | $1,071.52 | $1,737.80 | $3,311.31 |