- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.84 / $995.47 / $5,249.87
| Professional | | $841.84 | $995.47 | $5,249.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.84 / $1,606.84 / $1,606.84
| Facility | | $1,606.84 | $1,606.84 | $1,606.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.27 / $1,606.84 / $2,889.56
| Professional | | $942.27 | $1,606.84 | $2,889.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $991.59 / $1,325.49 / $1,828.56
| Facility | | $991.59 | $1,325.49 | $1,828.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.23 / $1,638.63 / $2,730.54
| Professional | | $1,007.23 | $1,638.63 | $2,730.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.89 / $1,697.92 / $2,227.00
| Professional | | $1,395.89 | $1,697.92 | $2,227.00 |