- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.75 / $1,037.58 / $5,477.80
| Professional | | $862.75 | $1,037.58 | $5,477.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.25 / $1,676.25 / $1,676.25
| Facility | | $1,676.25 | $1,676.25 | $1,676.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.61 / $1,676.25 / $2,922.41
| Professional | | $978.61 | $1,676.25 | $2,922.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.42 / $1,415.01 / $1,892.44
| Facility | | $1,032.42 | $1,415.01 | $1,892.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.47 / $1,714.12 / $2,856.33
| Professional | | $1,044.47 | $1,714.12 | $2,856.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.06 / $1,776.45 / $2,223.84
| Professional | | $1,448.06 | $1,776.45 | $2,223.84 |