- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.20 / $1,786.52 / $1,858.42
| Professional | | $908.20 | $1,786.52 | $1,858.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.33 / $1,477.62 / $2,198.76
| Professional | | $1,156.33 | $1,477.62 | $2,198.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.64 / $2,075.26 / $2,483.91
| Professional | | $1,425.64 | $2,075.26 | $2,483.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.55 / $1,632.01 / $2,503.59
| Professional | | $1,410.55 | $1,632.01 | $2,503.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.20 / $1,786.52 / $1,863.81
| Professional | | $908.20 | $1,786.52 | $1,863.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.10 / $1,555.63 / $2,011.59
| Professional | | $1,124.10 | $1,555.63 | $2,011.59 |