- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,288.25
| Professional | | $758.58 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $1,479.11
| Facility | | $1,258.93 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,479.11
| Professional | | $1,071.52 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,290.87
| Professional | | $1,348.96 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,348.96
| Facility | | $954.99 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,288.25 / $3,548.13
| Professional | | $588.84 | $1,288.25 | $3,548.13 |