- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,659.59
| Professional | | $812.83 | $1,023.29 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $3,235.94
| Facility | | $1,380.38 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,511.89
| Professional | | $1,023.29 | $1,023.29 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,047.13 / $2,398.83
| Facility | | $602.56 | $1,047.13 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $851.14 / $1,318.26
| Professional | | $588.84 | $851.14 | $1,318.26 |