- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $1,698.24
| Professional | | $891.25 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,412.54
| Professional | | $1,071.52 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,398.83 / $7,079.46
| Professional | | $1,148.15 | $2,398.83 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,238.72
| Professional | | $1,258.93 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,949.84
| Facility | | $794.33 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $2,398.83
| Professional | | $933.25 | $1,445.44 | $2,398.83 |