- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.59 / $1,373.28 / $1,716.60
| Professional | | $800.59 | $1,373.28 | $1,716.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $2,550.10
| Facility | | $1,450.41 | $1,450.41 | $2,550.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $3,787.50
| Professional | | $184.74 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.11 / $1,441.94 / $11,728.00
| Facility | | $209.11 | $1,441.94 | $11,728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.30 / $1,168.69 / $1,739.25
| Professional | | $751.30 | $1,168.69 | $1,739.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.74 / $1,100.01 / $1,736.33
| Professional | | $809.74 | $1,100.01 | $1,736.33 |