- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.73 / $2,321.98 / $2,554.17
| Professional | | $706.73 | $2,321.98 | $2,554.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,919.65 / $2,329.59 / $3,134.04
| Facility | | $1,919.65 | $2,329.59 | $3,134.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.49 / $1,942.13 / $2,291.71
| Professional | | $1,359.49 | $1,942.13 | $2,291.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.80 / $2,372.07 / $3,482.72
| Facility | | $1,686.80 | $2,372.07 | $3,482.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.55 / $804.55 / $804.55
| Professional | | $804.55 | $804.55 | $804.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.31 / $1,444.74 / $1,974.01
| Facility | | $1,330.31 | $1,444.74 | $1,974.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.23 / $1,153.64 / $1,459.13
| Professional | | $865.23 | $1,153.64 | $1,459.13 |