- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.54 / $1,221.23 / $1,616.82
| Professional | | $910.54 | $1,221.23 | $1,616.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.48 / $2,573.83 / $4,653.39
| Facility | | $712.48 | $2,573.83 | $4,653.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.20 / $2,374.94 / $3,235.85
| Professional | | $1,781.20 | $2,374.94 | $3,235.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $1,271.83
| Facility | | $1,271.83 | $1,271.83 | $1,271.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $928.44 / $2,707.13
| Professional | | $928.44 | $928.44 | $2,707.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.54 / $1,813.31 / $11,043.30
| Facility | | $655.54 | $1,813.31 | $11,043.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.76 / $1,015.43 / $1,564.74
| Professional | | $917.76 | $1,015.43 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.76 / $1,015.43 / $1,529.60
| Professional | | $917.76 | $1,015.43 | $1,529.60 |