- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.58 / $1,192.02 / $2,210.32
| Professional | | $752.58 | $1,192.02 | $2,210.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.68 / $1,639.62 / $2,962.50
| Professional | | $1,393.68 | $1,639.62 | $2,962.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.10 / $1,841.10 / $1,841.10
| Professional | | $1,841.10 | $1,841.10 | $1,841.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.28 / $1,509.28 / $1,509.28
| Professional | | $1,509.28 | $1,509.28 | $1,509.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.11 / $1,298.13 / $2,457.88
| Professional | | $1,023.11 | $1,298.13 | $2,457.88 |