- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.51 / $1,060.17 / $1,242.73
| Professional | | $915.51 | $1,060.17 | $1,242.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,962.50 / $4,001.22 / $4,736.97
| Facility | | $2,962.50 | $4,001.22 | $4,736.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.29 / $1,368.58 / $1,894.83
| Professional | | $1,163.29 | $1,368.58 | $1,894.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.20 / $1,184.20 / $1,211.99
| Facility | | $1,184.20 | $1,184.20 | $1,211.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.47 / $1,184.20 / $1,184.20
| Professional | | $864.47 | $1,184.20 | $1,184.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.60 / $1,045.33 / $1,742.23
| Professional | | $799.60 | $1,045.33 | $1,742.23 |