- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $2,398.83
| Professional | | $977.24 | $1,148.15 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $2,570.40
| Professional | | $977.24 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,819.70
| Facility | | $977.24 | $977.24 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,511.89
| Professional | | $812.83 | $1,412.54 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $3,019.95
| Professional | | $1,174.90 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $3,311.31
| Professional | | $1,000.00 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $2,454.71
| Professional | | $1,047.13 | $1,445.44 | $2,454.71 |