- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.18 / $1,012.62 / $1,444.41
| Professional | | $932.18 | $1,012.62 | $1,444.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.73 / $1,737.33 / $1,737.33
| Professional | | $1,476.73 | $1,737.33 | $1,737.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.00 / $1,440.00 / $1,468.00
| Professional | | $1,224.00 | $1,440.00 | $1,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.13 / $1,459.43 / $2,432.38
| Professional | | $1,080.13 | $1,459.43 | $2,432.38 |