- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.07 / $1,050.74 / $1,196.53
| Professional | | $774.07 | $1,050.74 | $1,196.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,504.82 / $3,383.09 / $4,005.18
| Facility | | $2,504.82 | $3,383.09 | $4,005.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.04 / $931.04 / $1,557.09
| Professional | | $931.04 | $931.04 | $1,557.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,024.74 / $1,107.01 / $1,107.01
| Facility | | $1,024.74 | $1,107.01 | $1,107.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.12 / $1,533.73 / $1,660.99
| Professional | | $808.12 | $1,533.73 | $1,660.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $749.08 / $883.84 / $1,473.07
| Professional | | $749.08 | $883.84 | $1,473.07 |