- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.33 / $1,224.01 / $6,456.87
| Professional | | $1,027.33 | $1,224.01 | $6,456.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.43 / $1,975.43 / $1,975.43
| Facility | | $1,975.43 | $1,975.43 | $1,975.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.21 / $1,975.43 / $3,530.32
| Professional | | $1,156.21 | $1,975.43 | $3,530.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.72 / $1,634.77 / $2,240.32
| Facility | | $1,217.72 | $1,634.77 | $2,240.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.96 / $2,017.69 / $3,362.19
| Professional | | $1,235.96 | $2,017.69 | $3,362.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.17 / $2,107.30 / $3,135.57
| Professional | | $1,677.17 | $2,107.30 | $3,135.57 |