- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,137.96
| Professional | | $891.25 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,630.78
| Facility | | $1,621.81 | $1,621.81 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,884.03
| Professional | | $1,202.26 | $1,202.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $2,818.38
| Facility | | $1,348.96 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,023.29 / $1,548.82
| Professional | | $676.08 | $1,023.29 | $1,548.82 |