- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $2,041.74
| Professional | | $741.31 | $977.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,348.96
| Professional | | $933.25 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $1,659.59
| Facility | | $1,412.54 | $1,445.44 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $1,659.59
| Professional | | $1,412.54 | $1,445.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $1,445.44
| Facility | | $724.44 | $1,148.15 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $870.96 / $1,737.80
| Professional | | $79.43 | $870.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,041.74
| Professional | | $1,148.15 | $1,380.38 | $2,041.74 |