- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.59 / $1,161.33 / $2,080.94
| Professional | | $800.59 | $1,161.33 | $2,080.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $3,787.50
| Professional | | $1,232.84 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,197.70 / $3,197.70 / $3,197.70
| Professional | | $3,197.70 | $3,197.70 | $3,197.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.60 / $1,671.60 / $1,671.60
| Professional | | $1,671.60 | $1,671.60 | $1,671.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.77 / $1,267.25 / $2,016.69
| Professional | | $1,004.77 | $1,267.25 | $2,016.69 |