- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,819.70
| Professional | | $794.33 | $1,202.26 | $1,819.70 |
- 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
- $1,174.90 / $1,174.90 / $3,311.31
| Facility | | $1,174.90 | $1,174.90 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $2,570.40
| Professional | | $851.14 | $851.14 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $2,511.89
| Facility | | $1,230.27 | $1,412.54 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $933.25 / $1,412.54
| Professional | | $616.60 | $933.25 | $1,412.54 |