- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.74 / $1,089.46 / $5,752.80
| Professional | | $902.74 | $1,089.46 | $5,752.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.12 / $1,755.12 / $1,755.12
| Facility | | $1,755.12 | $1,755.12 | $1,755.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.70 / $1,755.12 / $2,907.87
| Professional | | $993.70 | $1,755.12 | $2,907.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.70 / $1,458.66 / $1,971.50
| Facility | | $1,084.70 | $1,458.66 | $1,971.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.33 / $1,795.00 / $2,991.11
| Professional | | $1,091.33 | $1,795.00 | $2,991.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.51 / $1,832.32 / $2,333.56
| Professional | | $1,519.51 | $1,832.32 | $2,333.56 |