- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.57 / $1,154.55 / $6,087.00
| Professional | | $976.57 | $1,154.55 | $6,087.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.89 / $1,882.89 / $1,882.89
| Facility | | $1,882.89 | $1,882.89 | $1,882.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.14 / $1,882.89 / $3,348.06
| Professional | | $1,090.14 | $1,882.89 | $3,348.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.89 / $1,536.75 / $2,125.19
| Facility | | $1,161.89 | $1,536.75 | $2,125.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.10 / $1,920.09 / $3,199.56
| Professional | | $1,173.10 | $1,920.09 | $3,199.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.45 / $1,973.76 / $2,575.67
| Professional | | $1,614.45 | $1,973.76 | $2,575.67 |