- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.43 / $1,254.00 / $1,605.07
| Professional | | $1,182.43 | $1,254.00 | $1,605.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,826.24 / $5,167.83 / $6,118.11
| Facility | | $3,826.24 | $5,167.83 | $6,118.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.88 / $1,422.21 / $2,378.53
| Professional | | $1,208.88 | $1,422.21 | $2,378.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.36 / $1,606.19 / $1,606.19
| Facility | | $1,565.36 | $1,606.19 | $1,606.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.52 / $1,606.19 / $1,606.19
| Professional | | $1,172.52 | $1,606.19 | $1,606.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.26 / $1,545.50 / $2,250.19
| Professional | | $1,220.26 | $1,545.50 | $2,250.19 |