- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.18 / $1,380.81 / $2,474.37
| Professional | | $915.18 | $1,380.81 | $2,474.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.69 / $1,219.64 / $3,465.00
| Professional | | $1,036.69 | $1,219.64 | $3,465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,755.17 / $5,755.17 / $5,755.17
| Professional | | $5,755.17 | $5,755.17 | $5,755.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.60 / $1,987.60 / $1,987.60
| Professional | | $1,987.60 | $1,987.60 | $1,987.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.68 / $1,465.21 / $1,909.39
| Professional | | $1,148.68 | $1,465.21 | $1,909.39 |