- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.07 / $1,133.69 / $5,983.62
| Professional | | $942.07 | $1,133.69 | $5,983.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.10 / $1,826.10 / $1,826.10
| Facility | | $1,826.10 | $1,826.10 | $1,826.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.77 / $1,826.10 / $3,249.13
| Professional | | $1,070.77 | $1,826.10 | $3,249.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.58 / $1,475.80 / $2,058.79
| Facility | | $1,125.58 | $1,475.80 | $2,058.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.73 / $1,866.71 / $3,110.61
| Professional | | $1,144.73 | $1,866.71 | $3,110.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.36 / $1,906.55 / $2,527.69
| Professional | | $1,584.36 | $1,906.55 | $2,527.69 |