- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.04 / $1,172.84 / $1,241.06
| Professional | | $870.04 | $1,172.84 | $1,241.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.72 / $1,492.72 / $2,331.50
| Professional | | $1,492.72 | $1,492.72 | $2,331.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $2,111.63
| Professional | | $1,506.25 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.84 / $1,131.32 / $1,508.42
| Facility | | $150.84 | $1,131.32 | $1,508.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.05 / $1,364.31 / $2,273.85
| Professional | | $928.05 | $1,364.31 | $2,273.85 |