- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,445.44
| Professional | | $794.33 | $1,096.48 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,584.89
| Facility | | $1,412.54 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,412.54
| Professional | | $1,023.29 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $2,454.71
| Professional | | $1,659.59 | $2,089.30 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,230.27 / $1,445.44
| Facility | | $1,202.26 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,621.81 / $4,466.84
| Professional | | $741.31 | $1,621.81 | $4,466.84 |