- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $851.14 / $2,290.87
| Professional | | $831.76 | $851.14 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $3,715.35
| Professional | | $1,905.46 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,698.24
| Professional | | $794.33 | $1,202.26 | $1,698.24 |
- 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
- $977.24 / $1,862.09 / $3,090.30
| Professional | | $977.24 | $1,862.09 | $3,090.30 |