- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.73 / $1,231.63 / $1,403.49
| Professional | | $939.73 | $1,231.63 | $1,403.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.31 / $1,055.77 / $1,055.77
| Professional | | $971.31 | $1,055.77 | $1,055.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,422.22
| Facility | | $1,116.58 | $1,116.58 | $1,422.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,974.00
| Professional | | $949.10 | $1,116.58 | $1,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.85 / $858.28 / $1,360.52
| Professional | | $572.85 | $858.28 | $1,360.52 |