- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.63 / $1,410.91 / $2,601.65
| Professional | | $963.63 | $1,410.91 | $2,601.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Facility | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.58 / $1,572.58 / $4,560.93
| Professional | | $1,572.58 | $1,572.58 | $4,560.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.60 / $2,325.60 / $2,325.60
| Professional | | $2,325.60 | $2,325.60 | $2,325.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.52 / $2,073.52 / $2,073.52
| Professional | | $2,073.52 | $2,073.52 | $2,073.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.14 / $1,887.48 / $2,534.09
| Professional | | $1,555.14 | $1,887.48 | $2,534.09 |