- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.37 / $1,037.11 / $4,947.83
| Professional | | $880.37 | $1,037.11 | $4,947.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.94 / $1,506.94 / $1,506.94
| Facility | | $1,506.94 | $1,506.94 | $1,506.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.45 / $1,506.94 / $1,506.94
| Professional | | $1,143.45 | $1,506.94 | $1,506.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.94 / $1,799.20 / $1,869.67
| Facility | | $1,506.94 | $1,799.20 | $1,869.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.71 / $1,302.95 / $1,990.10
| Professional | | $919.71 | $1,302.95 | $1,990.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.68 / $1,679.40 / $2,636.26
| Professional | | $1,411.68 | $1,679.40 | $2,636.26 |