- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.31 / $1,071.57 / $5,549.26
| Professional | | $1,066.31 | $1,071.57 | $5,549.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.18 / $1,695.18 / $1,695.18
| Facility | | $1,695.18 | $1,695.18 | $1,695.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.48 / $1,695.18 / $1,695.18
| Professional | | $1,229.48 | $1,695.18 | $1,695.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.18 / $1,963.00 / $2,116.35
| Facility | | $1,695.18 | $1,963.00 | $2,116.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.94 / $1,463.35 / $2,235.10
| Professional | | $1,032.94 | $1,463.35 | $2,235.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.98 / $1,880.40 / $2,960.92
| Professional | | $1,472.98 | $1,880.40 | $2,960.92 |