- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,238.72
| Professional | | $891.25 | $1,258.93 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $1,659.59
| Facility | | $1,513.56 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $1,659.59
| Professional | | $1,513.56 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $1,905.46
| Facility | | $912.01 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,230.27 / $1,949.84
| Professional | | $79.43 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $1,698.24
| Professional | | $1,148.15 | $1,479.11 | $1,698.24 |