- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,348.96
| Professional | | $933.25 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,584.89
| Facility | | $1,230.27 | $1,230.27 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,230.27
| Professional | | $891.25 | $891.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $2,630.27
| Professional | | $1,659.59 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,548.82
| Facility | | $1,288.25 | $1,288.25 | $1,548.82 |
- 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 |