- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.08 / $1,115.23 / $1,195.50
| Professional | | $963.08 | $1,115.23 | $1,195.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,859.75 / $1,859.75 / $1,859.75
| Facility | | $1,859.75 | $1,859.75 | $1,859.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.84 / $1,859.75 / $3,507.27
| Professional | | $1,151.84 | $1,859.75 | $3,507.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.81 / $1,194.25 / $2,229.55
| Facility | | $851.81 | $1,194.25 | $2,229.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.58 / $1,616.53 / $2,604.84
| Professional | | $1,077.58 | $1,616.53 | $2,604.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.87 / $1,779.48 / $2,215.94
| Professional | | $1,525.87 | $1,779.48 | $2,215.94 |