- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.16 / $1,127.00 / $1,483.88
| Professional | | $1,093.16 | $1,127.00 | $1,483.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,537.37 / $4,777.68 / $5,656.22
| Facility | | $3,537.37 | $4,777.68 | $5,656.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.15 / $1,634.15 / $2,262.52
| Professional | | $1,634.15 | $1,634.15 | $2,262.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,447.16
| Facility | | $1,172.51 | $1,172.51 | $1,447.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $1,172.51 / $1,172.51
| Professional | | $855.93 | $1,172.51 | $1,172.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.12 / $1,248.18 / $2,080.30
| Professional | | $832.12 | $1,248.18 | $2,080.30 |