- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.37 / $1,128.86 / $5,997.21
| Professional | | $963.37 | $1,128.86 | $5,997.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,834.52 / $1,834.52 / $1,834.52
| Facility | | $1,834.52 | $1,834.52 | $1,834.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.65 / $1,834.52 / $3,289.97
| Professional | | $1,058.65 | $1,834.52 | $3,289.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.86 / $1,445.71 / $2,090.41
| Facility | | $1,073.86 | $1,445.71 | $2,090.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.63 / $1,873.18 / $3,121.39
| Professional | | $1,150.63 | $1,873.18 | $3,121.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.11 / $1,940.48 / $2,546.42
| Professional | | $1,596.11 | $1,940.48 | $2,546.42 |