- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.21 / $1,113.80 / $5,845.77
| Professional | | $944.21 | $1,113.80 | $5,845.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,792.98 / $1,792.98 / $1,792.98
| Facility | | $1,792.98 | $1,792.98 | $1,792.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.63 / $1,792.98 / $3,170.89
| Professional | | $1,084.63 | $1,792.98 | $3,170.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.68 / $1,478.46 / $2,046.77
| Facility | | $1,106.68 | $1,478.46 | $2,046.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.58 / $1,830.04 / $3,049.51
| Professional | | $1,118.58 | $1,830.04 | $3,049.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.70 / $1,904.64 / $2,389.14
| Professional | | $1,555.70 | $1,904.64 | $2,389.14 |