- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,778.28
| Professional | | $891.25 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- 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
- $977.24 / $977.24 / $2,344.23
| Professional | | $977.24 | $977.24 | $2,344.23 |
- 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 |