- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,570.40
| Professional | | $912.01 | $1,348.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $1,584.89
| Professional | | $1,230.27 | $1,380.38 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,949.84 / $3,235.94
| Professional | | $1,122.02 | $1,949.84 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $2,137.96
| Professional | | $1,258.93 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,737.80
| Facility | | $794.33 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $2,041.74
| Professional | | $794.33 | $1,122.02 | $2,041.74 |