- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $2,290.87
| Professional | | $741.31 | $831.76 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,089.30
| Professional | | $1,445.44 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,187.76
| Professional | | $1,122.02 | $1,584.89 | $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
- $1,047.13 / $1,862.09 / $2,951.21
| Professional | | $1,047.13 | $1,862.09 | $2,951.21 |