- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.74 / $960.89 / $1,036.73
| Professional | | $530.74 | $960.89 | $1,036.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,471.44 / $3,338.00 / $3,951.80
| Facility | | $2,471.44 | $3,338.00 | $3,951.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.46 / $1,141.72 / $1,580.75
| Professional | | $970.46 | $1,141.72 | $1,580.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.20 / $1,162.20 / $1,433.06
| Facility | | $1,162.20 | $1,162.20 | $1,433.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.41 / $1,162.20 / $1,433.06
| Professional | | $848.41 | $1,162.20 | $1,433.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.48 / $931.20 / $1,453.44
| Professional | | $676.48 | $931.20 | $1,453.44 |