- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.13 / $1,023.93 / $5,357.98
| Professional | | $871.13 | $1,023.93 | $5,357.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.87 / $1,637.87 / $1,637.87
| Facility | | $1,637.87 | $1,637.87 | $1,637.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.82 / $1,637.87 / $2,963.11
| Professional | | $979.82 | $1,637.87 | $2,963.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.76 / $1,350.02 / $1,924.70
| Facility | | $1,010.76 | $1,350.02 | $1,924.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.58 / $1,641.86 / $2,735.93
| Professional | | $1,047.58 | $1,641.86 | $2,735.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.95 / $1,732.83 / $2,119.90
| Professional | | $1,399.95 | $1,732.83 | $2,119.90 |