- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.85 / $873.87 / $2,297.57
| Professional | | $709.85 | $873.87 | $2,297.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.47 / $1,392.32 / $1,392.32
| Professional | | $1,183.47 | $1,392.32 | $1,392.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.32 / $1,392.32 / $1,392.32
| Facility | | $1,392.32 | $1,392.32 | $1,392.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.13 / $1,253.08 / $1,985.12
| Professional | | $853.13 | $1,253.08 | $1,985.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.02 / $1,022.50 / $1,662.21
| Facility | | $648.02 | $1,022.50 | $1,662.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.83 / $1,505.63 / $2,381.02
| Professional | | $928.83 | $1,505.63 | $2,381.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.08 / $1,488.00 / $1,689.80
| Professional | | $1,195.08 | $1,488.00 | $1,689.80 |