- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.81 / $1,023.51 / $1,659.56
| Professional | | $768.81 | $1,023.51 | $1,659.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,034.49 / $2,685.94
| Professional | | $1,034.49 | $1,034.49 | $2,685.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.86 / $1,641.86 / $2,293.00
| Professional | | $1,641.86 | $1,641.86 | $2,293.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.89 / $1,289.89 / $1,289.89
| Professional | | $1,289.89 | $1,289.89 | $1,289.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.61 / $1,121.06 / $2,051.44
| Professional | | $904.61 | $1,121.06 | $2,051.44 |