- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.36 / $1,327.67 / $1,534.56
| Professional | | $728.36 | $1,327.67 | $1,534.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.80 / $1,556.80 / $1,901.61
| Professional | | $1,556.80 | $1,556.80 | $1,901.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,994.75
| Professional | | $1,241.43 | $1,460.50 | $2,994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.93 / $1,904.93 / $1,904.93
| Professional | | $1,904.93 | $1,904.93 | $1,904.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.67 / $1,095.38 / $1,817.84
| Professional | | $857.67 | $1,095.38 | $1,817.84 |