- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.03 / $1,158.51 / $4,123.34
| Professional | | $878.03 | $1,158.51 | $4,123.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.67 / $1,307.67 / $1,307.67
| Professional | | $1,307.67 | $1,307.67 | $1,307.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.66 / $1,307.66 / $1,307.66
| Facility | | $1,307.66 | $1,307.66 | $1,307.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.51 / $1,238.50 / $1,307.66
| Professional | | $626.51 | $1,238.50 | $1,307.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.01 / $841.93 / $1,307.66
| Facility | | $643.01 | $841.93 | $1,307.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.68 / $1,243.70 / $1,726.90
| Professional | | $797.68 | $1,243.70 | $1,726.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.50 / $1,260.00 / $1,426.05
| Professional | | $1,057.50 | $1,260.00 | $1,426.05 |