- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.72 / $1,133.61 / $1,305.46
| Professional | | $961.72 | $1,133.61 | $1,305.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,112.05 / $4,203.22 / $4,976.12
| Facility | | $3,112.05 | $4,203.22 | $4,976.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.01 / $1,437.66 / $1,990.48
| Professional | | $1,222.01 | $1,437.66 | $1,990.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,273.15
| Facility | | $1,179.41 | $1,179.41 | $1,273.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $1,179.40 / $1,179.41
| Professional | | $860.97 | $1,179.40 | $1,179.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.00 / $1,098.58 / $1,830.17
| Professional | | $855.00 | $1,098.58 | $1,830.17 |