- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.66 / $1,130.27 / $1,187.29
| Professional | | $874.66 | $1,130.27 | $1,187.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,830.32 / $3,822.75 / $4,525.68
| Facility | | $2,830.32 | $3,822.75 | $4,525.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.39 / $1,307.52 / $1,810.30
| Professional | | $1,111.39 | $1,307.52 | $1,810.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.90 / $1,277.46 / $1,277.46
| Facility | | $1,157.90 | $1,277.46 | $1,277.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $1,277.46 / $1,277.46
| Professional | | $932.55 | $1,277.46 | $1,277.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.71 / $1,070.06 / $1,664.51
| Professional | | $795.71 | $1,070.06 | $1,664.51 |