- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.51 / $1,043.79 / $1,584.48
| Professional | | $942.51 | $1,043.79 | $1,584.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.79 / $1,554.79 / $1,554.79
| Facility | | $1,554.79 | $1,554.79 | $1,554.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.17 / $1,554.79 / $1,888.01
| Professional | | $918.17 | $1,554.79 | $1,888.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.78 / $1,058.45 / $1,554.79
| Facility | | $769.78 | $1,058.45 | $1,554.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.88 / $1,554.79 / $2,128.39
| Professional | | $957.88 | $1,554.79 | $2,128.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.29 / $1,744.05 / $1,924.47
| Professional | | $1,442.29 | $1,744.05 | $1,924.47 |