- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.81 / $966.08 / $5,180.93
| Professional | | $748.81 | $966.08 | $5,180.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,522.19 / $1,522.19 / $1,522.19
| Facility | | $1,522.19 | $1,522.19 | $1,522.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.10 / $1,356.53 / $2,441.96
| Professional | | $881.10 | $1,356.53 | $2,441.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.81 / $1,346.69 / $1,775.43
| Facility | | $940.81 | $1,346.69 | $1,775.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.78 / $1,543.19 / $2,571.51
| Professional | | $942.78 | $1,543.19 | $2,571.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.74 / $1,591.52 / $2,131.03
| Professional | | $1,335.74 | $1,591.52 | $2,131.03 |