- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,698.24
| Professional | | $851.14 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,467.37
| Facility | | $1,288.25 | $1,288.25 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $2,398.83
| Professional | | $933.25 | $933.25 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,122.02 / $2,570.40
| Facility | | $630.96 | $1,122.02 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,412.54
| Professional | | $630.96 | $870.96 | $1,412.54 |