- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.49 / $1,246.09 / $1,246.09
| Professional | | $795.49 | $1,246.09 | $1,246.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.20 / $1,382.95 / $1,382.95
| Professional | | $1,220.20 | $1,382.95 | $1,382.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,496.40
| Facility | | $1,122.47 | $1,122.47 | $1,496.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.82 / $1,122.47 / $1,122.47
| Professional | | $140.82 | $1,122.47 | $1,122.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.54 / $985.38 / $1,246.09
| Professional | | $764.54 | $985.38 | $1,246.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.02 / $898.41 / $1,955.84
| Professional | | $590.02 | $898.41 | $1,955.84 |