- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.67 / $1,308.94 / $1,390.80
| Professional | | $819.67 | $1,308.94 | $1,390.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.02 / $1,522.02 / $1,522.02
| Professional | | $1,522.02 | $1,522.02 | $1,522.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.24 / $1,308.94 / $1,738.20
| Facility | | $1,162.24 | $1,308.94 | $1,738.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.37 / $828.50 / $1,759.61
| Professional | | $514.37 | $828.50 | $1,759.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.37 / $655.82 / $1,106.90
| Professional | | $514.37 | $655.82 | $1,106.90 |