- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.41 / $1,049.26 / $1,161.16
| Professional | | $855.41 | $1,049.26 | $1,161.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,768.03 / $3,738.59 / $4,426.05
| Facility | | $2,768.03 | $3,738.59 | $4,426.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.74 / $1,278.74 / $1,770.46
| Professional | | $1,278.74 | $1,278.74 | $1,770.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $1,108.41
| Facility | | $1,108.41 | $1,108.41 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $1,108.41 / $1,108.41
| Professional | | $809.14 | $1,108.41 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.68 / $976.72 / $1,627.86
| Professional | | $738.68 | $976.72 | $1,627.86 |