- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,737.80
| Professional | | $851.14 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $3,162.28
| Facility | | $1,096.48 | $1,096.48 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $2,630.27
| Professional | | $812.83 | $812.83 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,023.29 / $2,398.83
| Facility | | $602.56 | $1,023.29 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $1,318.26
| Professional | | $588.84 | $891.25 | $1,318.26 |