- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.16 / $1,142.33 / $6,029.14
| Professional | | $950.16 | $1,142.33 | $6,029.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,839.77 / $1,839.77 / $1,839.77
| Facility | | $1,839.77 | $1,839.77 | $1,839.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.91 / $1,839.77 / $3,223.56
| Professional | | $1,057.91 | $1,839.77 | $3,223.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,065.56 / $1,477.13 / $2,082.82
| Facility | | $1,065.56 | $1,477.13 | $2,082.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.78 / $1,881.27 / $3,134.87
| Professional | | $1,152.78 | $1,881.27 | $3,134.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.58 / $1,970.25 / $3,223.62
| Professional | | $1,596.58 | $1,970.25 | $3,223.62 |