- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.19 / $1,129.64 / $1,186.93
| Professional | | $832.19 | $1,129.64 | $1,186.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,692.89 / $3,637.10 / $4,305.89
| Facility | | $2,692.89 | $3,637.10 | $4,305.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.94 / $1,000.94 / $1,674.00
| Professional | | $1,000.94 | $1,000.94 | $1,674.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.30 / $1,551.30 / $1,551.30
| Facility | | $1,551.30 | $1,551.30 | $1,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.45 / $1,551.30 / $1,551.30
| Professional | | $1,132.45 | $1,551.30 | $1,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.81 / $1,214.06 / $1,583.67
| Professional | | $858.81 | $1,214.06 | $1,583.67 |