- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $912.01 / $2,454.71
| Professional | | $870.96 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,311.31 / $3,981.07
| Professional | | $2,041.74 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $1,995.26
| Professional | | $1,096.48 | $1,659.59 | $1,995.26 |
- 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 / $1,995.26 / $3,090.30
| Professional | | $1,047.13 | $1,995.26 | $3,090.30 |