- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,445.44
| Professional | | $776.25 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $1,513.56
| Facility | | $1,288.25 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,513.56
| Professional | | $1,096.48 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,344.23
| Professional | | $1,380.38 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,174.90 / $1,380.38
| Facility | | $1,148.15 | $1,174.90 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,318.26 / $3,715.35
| Professional | | $616.60 | $1,318.26 | $3,715.35 |