- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.22 / $1,086.81 / $2,103.21
| Professional | | $791.22 | $1,086.81 | $2,103.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,994.75
| Professional | | $1,241.43 | $1,460.50 | $2,994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.85 / $2,359.85 / $2,376.44
| Professional | | $2,359.85 | $2,359.85 | $2,376.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.24 / $1,747.08 / $1,747.08
| Professional | | $1,718.24 | $1,747.08 | $1,747.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.24 / $1,288.68 / $1,650.76
| Professional | | $1,033.24 | $1,288.68 | $1,650.76 |