- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $3,162.28
| Professional | | $977.24 | $1,348.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $1,659.59
| Professional | | $1,230.27 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $3,019.95
| Professional | | $1,047.13 | $1,548.82 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,041.74
| Professional | | $1,202.26 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,344.23
| Professional | | $977.24 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $1,819.70
| Professional | | $1,071.52 | $1,513.56 | $1,819.70 |