- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.42 / $1,177.52 / $6,210.76
| Professional | | $989.42 | $1,177.52 | $6,210.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,904.45 / $1,904.45 / $1,904.45
| Facility | | $1,904.45 | $1,904.45 | $1,904.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.47 / $1,904.45 / $3,361.70
| Professional | | $1,112.47 | $1,904.45 | $3,361.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.79 / $1,573.92 / $2,155.56
| Facility | | $1,174.79 | $1,573.92 | $2,155.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.16 / $1,942.20 / $3,236.40
| Professional | | $1,189.16 | $1,942.20 | $3,236.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.17 / $2,001.27 / $2,534.21
| Professional | | $1,650.17 | $2,001.27 | $2,534.21 |