- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,754.23
| Professional | | $676.08 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,786.30 / $5,754.40
| Professional | | $2,951.21 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $3,630.78
| Professional | | $1,819.70 | $2,818.38 | $3,630.78 |
- 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
- $1,659.59 / $2,691.53 / $5,888.44
| Professional | | $1,659.59 | $2,691.53 | $5,888.44 |