- 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
- $1,819.70 / $2,290.87 / $2,754.23
| Professional | | $1,819.70 | $2,290.87 | $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
- $4,168.69 / $4,365.16 / $14,125.38
| Facility | | $4,168.69 | $4,365.16 | $14,125.38 |
- 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 |