- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $1,698.24
| Professional | | $977.24 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,862.09
| Facility | | $1,412.54 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,479.11
| Professional | | $1,047.13 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $3,019.95
| Professional | | $1,995.26 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,819.70
| Facility | | $1,348.96 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,905.46 / $5,248.07
| Professional | | $870.96 | $1,905.46 | $5,248.07 |