- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,380.38
| Professional | | $891.25 | $1,230.27 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,621.81 / $1,621.81
| Facility | | $1,513.56 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,621.81
| Professional | | $1,202.26 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,754.23
| Professional | | $1,621.81 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $1,621.81
| Facility | | $1,348.96 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,548.82 / $4,265.80
| Professional | | $707.95 | $1,548.82 | $4,265.80 |