- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.78 / $1,085.77 / $5,233.38
| Professional | | $977.78 | $1,085.77 | $5,233.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.27 / $1,087.84 / $1,430.23
| Professional | | $1,064.27 | $1,087.84 | $1,430.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.35 / $3,076.35 / $3,076.35
| Facility | | $3,076.35 | $3,076.35 | $3,076.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.27 / $1,342.65 / $2,563.17
| Professional | | $949.27 | $1,342.65 | $2,563.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.47 / $1,362.55 / $2,268.00
| Professional | | $1,024.47 | $1,362.55 | $2,268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.03 / $1,184.97 / $1,996.87
| Professional | | $879.03 | $1,184.97 | $1,996.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.60 / $1,178.14 / $1,457.22
| Professional | | $906.60 | $1,178.14 | $1,457.22 |