- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.27 / $995.77 / $1,574.36
| Professional | | $824.27 | $995.77 | $1,574.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,080.00 / $1,376.72
| Professional | | $1,080.00 | $1,080.00 | $1,376.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,544.16
| Facility | | $1,544.16 | $1,544.16 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,127.24 / $1,544.16
| Professional | | $1,127.24 | $1,127.24 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.77 / $2,013.95 / $2,900.09
| Professional | | $1,409.77 | $2,013.95 | $2,900.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.19 / $1,004.74 / $1,601.53
| Professional | | $907.19 | $1,004.74 | $1,601.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.56 / $1,206.56 / $1,409.77
| Professional | | $1,206.56 | $1,206.56 | $1,409.77 |