- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.65 / $1,017.19 / $1,218.58
| Professional | | $877.65 | $1,017.19 | $1,218.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.60 / $3,163.03 / $6,101.28
| Facility | | $1,605.60 | $3,163.03 | $6,101.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.08 / $1,302.19 / $1,627.74
| Professional | | $530.08 | $1,302.19 | $1,627.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.77 / $2,087.28 / $3,163.03
| Facility | | $930.77 | $2,087.28 | $3,163.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.56 / $1,403.31 / $2,018.45
| Professional | | $990.56 | $1,403.31 | $2,018.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.17 / $415.17 / $1,060.16
| Professional | | $415.17 | $415.17 | $1,060.16 |