- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $870.96 / $1,513.56
| Professional | | $812.83 | $870.96 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $3,019.95
| Professional | | $1,995.26 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $2,398.83
| Professional | | $1,047.13 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,370.32
| Facility | | $1,288.25 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,584.89 / $3,388.44
| Professional | | $912.01 | $1,584.89 | $3,388.44 |