- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $812.83 / $1,412.54
| Professional | | $741.31 | $812.83 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $2,818.38
| Professional | | $1,548.82 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,479.11 / $2,238.72
| Professional | | $870.96 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,754.23 / $5,370.32
| Facility | | $1,288.25 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,445.44 / $3,019.95
| Professional | | $741.31 | $1,445.44 | $3,019.95 |