- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.16 / $1,051.26 / $5,204.64
| Professional | | $982.16 | $1,051.26 | $5,204.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,534.28 / $1,534.28 / $1,534.28
| Facility | | $1,534.28 | $1,534.28 | $1,534.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.58 / $1,534.28 / $1,534.28
| Professional | | $1,185.58 | $1,534.28 | $1,534.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,534.28 / $1,836.25 / $1,905.72
| Facility | | $1,534.28 | $1,836.25 | $1,905.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.21 / $1,310.74 / $2,002.00
| Professional | | $925.21 | $1,310.74 | $2,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.75 / $1,752.74 / $3,956.05
| Professional | | $1,440.75 | $1,752.74 | $3,956.05 |