- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $1,621.81
| Professional | | $831.76 | $912.01 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $3,630.78
| Professional | | $1,862.09 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $2,290.87
| Professional | | $1,122.02 | $1,698.24 | $2,290.87 |
- 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 / $1,659.59 / $3,548.13
| Professional | | $977.24 | $1,659.59 | $3,548.13 |