- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.10 / $1,138.60 / $1,907.25
| Professional | | $886.10 | $1,138.60 | $1,907.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.00 / $1,154.00 / $1,471.83
| Professional | | $1,154.00 | $1,154.00 | $1,471.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $1,271.83
| Facility | | $1,271.83 | $1,271.83 | $1,271.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $928.44 / $1,271.83
| Professional | | $928.44 | $928.44 | $1,271.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.16 / $2,153.08 / $3,100.44
| Professional | | $1,507.16 | $2,153.08 | $3,100.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.86 / $1,111.09 / $1,703.31
| Professional | | $969.86 | $1,111.09 | $1,703.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.63 / $1,231.63 / $1,507.16
| Professional | | $1,231.63 | $1,231.63 | $1,507.16 |