- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.38 / $1,000.77 / $1,686.68
| Professional | | $953.38 | $1,000.77 | $1,686.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.85 / $2,372.86 / $4,290.04
| Facility | | $656.85 | $2,372.86 | $4,290.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.12 / $2,189.48 / $2,983.18
| Professional | | $1,642.12 | $2,189.48 | $2,983.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,172.51
| Facility | | $1,172.51 | $1,172.51 | $1,172.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $855.93 / $2,316.38
| Professional | | $855.93 | $855.93 | $2,316.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.35 / $1,671.72 / $9,934.14
| Facility | | $604.35 | $1,671.72 | $9,934.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.25 / $936.14 / $1,410.16
| Professional | | $845.25 | $936.14 | $1,410.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.10 / $936.14 / $1,410.16
| Professional | | $846.10 | $936.14 | $1,410.16 |