- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.98 / $1,660.30 / $2,075.38
| Professional | | $967.98 | $1,660.30 | $2,075.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,491.32
| Facility | | $1,786.79 | $1,786.79 | $2,491.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $3,663.75
| Professional | | $1,518.77 | $1,786.79 | $3,663.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.13 / $2,035.61 / $14,043.28
| Facility | | $865.13 | $2,035.61 | $14,043.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.39 / $1,510.76 / $2,102.88
| Professional | | $908.39 | $1,510.76 | $2,102.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.75 / $1,424.93 / $2,099.40
| Professional | | $1,116.75 | $1,424.93 | $2,099.40 |