- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.76 / $1,129.92 / $5,964.35
| Professional | | $938.76 | $1,129.92 | $5,964.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,817.16 / $1,817.16 / $1,817.16
| Facility | | $1,817.16 | $1,817.16 | $1,817.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.26 / $1,817.16 / $3,158.86
| Professional | | $1,054.26 | $1,817.16 | $3,158.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.03 / $1,475.80 / $2,060.05
| Facility | | $1,104.03 | $1,475.80 | $2,060.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.34 / $1,858.62 / $3,097.13
| Professional | | $1,142.34 | $1,858.62 | $3,097.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.26 / $1,900.81 / $2,423.78
| Professional | | $1,578.26 | $1,900.81 | $2,423.78 |