- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.13 / $1,329.61 / $2,616.88
| Professional | | $943.13 | $1,329.61 | $2,616.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $3,663.75
| Professional | | $1,518.77 | $1,786.79 | $3,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.05 / $2,887.05 / $2,907.37
| Professional | | $2,887.05 | $2,887.05 | $2,907.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.16 / $1,891.36 / $1,891.36
| Professional | | $96.16 | $1,891.36 | $1,891.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.34 / $1,418.52 / $1,817.11
| Professional | | $1,137.34 | $1,418.52 | $1,817.11 |