- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,737.80
| Professional | | $870.96 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $3,235.94
| Facility | | $1,318.26 | $1,318.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,344.23
| Professional | | $954.99 | $954.99 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,454.71
| Facility | | $1,202.26 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,412.54
| Professional | | $602.56 | $954.99 | $1,412.54 |