- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.49 / $1,338.57 / $6,247.56
| Professional | | $909.49 | $1,338.57 | $6,247.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.86 / $1,912.86 / $1,912.86
| Facility | | $1,912.86 | $1,912.86 | $1,912.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.55 / $1,912.86 / $1,912.86
| Professional | | $1,064.55 | $1,912.86 | $1,912.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.74 / $1,858.29 / $1,912.86
| Facility | | $942.74 | $1,858.29 | $1,912.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.59 / $1,672.67 / $2,520.00
| Professional | | $1,164.59 | $1,672.67 | $2,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.00 / $1,996.56 / $3,363.30
| Professional | | $1,537.00 | $1,996.56 | $3,363.30 |