- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.64 / $1,186.50 / $1,256.74
| Professional | | $966.64 | $1,186.50 | $1,256.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.58 / $1,322.05 / $2,208.96
| Professional | | $1,021.58 | $1,322.05 | $2,208.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.88 / $1,336.88 / $1,336.88
| Facility | | $1,336.88 | $1,336.88 | $1,336.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.26 / $1,347.08 / $2,569.85
| Professional | | $1,025.26 | $1,347.08 | $2,569.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.24 / $1,886.31 / $3,289.55
| Professional | | $1,281.24 | $1,886.31 | $3,289.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.64 / $974.43 / $1,256.74
| Professional | | $966.64 | $974.43 | $1,256.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.27 / $1,374.66 / $2,056.01
| Professional | | $907.27 | $1,374.66 | $2,056.01 |