- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.67 / $1,428.58 / $1,499.00
| Professional | | $1,092.67 | $1,428.58 | $1,499.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,535.77 / $4,775.54 / $5,653.67
| Facility | | $3,535.77 | $4,775.54 | $5,653.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.41 / $1,633.42 / $2,261.50
| Professional | | $1,388.41 | $1,633.42 | $2,261.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,446.51 / $1,486.28 / $1,486.28
| Facility | | $1,446.51 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,486.28 / $1,486.28
| Professional | | $1,084.98 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.39 / $1,593.82 / $2,079.37
| Professional | | $1,174.39 | $1,593.82 | $2,079.37 |