- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.32 / $939.12 / $5,213.46
| Professional | | $893.32 | $939.12 | $5,213.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.44 / $1,588.44 / $1,588.44
| Facility | | $1,588.44 | $1,588.44 | $1,588.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.45 / $1,588.44 / $1,588.44
| Professional | | $1,189.45 | $1,588.44 | $1,588.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.44 / $1,757.60 / $1,827.93
| Facility | | $1,588.44 | $1,757.60 | $1,827.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.50 / $1,374.90 / $2,100.00
| Professional | | $970.50 | $1,374.90 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.96 / $1,757.59 / $2,778.69
| Professional | | $1,386.96 | $1,757.59 | $2,778.69 |