- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.20 / $1,131.01 / $1,489.91
| Professional | | $828.20 | $1,131.01 | $1,489.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.70 / $1,358.65 / $1,480.28
| Facility | | $1,237.70 | $1,358.65 | $1,480.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.10 / $1,245.43 / $1,315.80
| Professional | | $675.10 | $1,245.43 | $1,315.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.88 / $1,336.88 / $1,336.88
| Facility | | $1,336.88 | $1,336.88 | $1,336.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.08 / $1,278.99 / $2,277.30
| Professional | | $922.08 | $1,278.99 | $2,277.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.51 / $1,028.04 / $1,527.79
| Professional | | $695.51 | $1,028.04 | $1,527.79 |