- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.93 / $1,091.96 / $2,149.16
| Professional | | $794.93 | $1,091.96 | $2,149.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,221.04 / $3,759.38
| Professional | | $1,221.04 | $1,221.04 | $3,759.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,854.81 / $4,854.81 / $4,854.81
| Professional | | $4,854.81 | $4,854.81 | $4,854.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.40 / $1,726.40 / $1,726.40
| Professional | | $1,726.40 | $1,726.40 | $1,726.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.64 / $1,236.64 / $2,390.13
| Professional | | $997.64 | $1,236.64 | $2,390.13 |