- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.78 / $5,233.38 / $5,233.38
| Professional | | $1,029.78 | $5,233.38 | $5,233.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,569.51 / $1,569.51 / $1,569.51
| Facility | | $1,569.51 | $1,569.51 | $1,569.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.04 / $1,569.51 / $1,705.26
| Professional | | $1,119.04 | $1,569.51 | $1,705.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $767.42 / $1,764.75 / $1,911.42
| Facility | | $767.42 | $1,764.75 | $1,911.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.56 / $1,436.49 / $2,072.00
| Professional | | $957.56 | $1,436.49 | $2,072.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.65 / $1,679.73 / $2,762.04
| Professional | | $1,384.65 | $1,679.73 | $2,762.04 |