- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.83 / $996.99 / $1,144.07
| Professional | | $842.83 | $996.99 | $1,144.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,727.31 / $3,683.60 / $4,360.95
| Facility | | $2,727.31 | $3,683.60 | $4,360.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.85 / $1,303.36 / $1,744.40
| Professional | | $1,107.85 | $1,303.36 | $1,744.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.25 / $1,037.25 / $1,037.25
| Facility | | $1,037.25 | $1,037.25 | $1,037.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.19 / $1,037.25 / $1,037.25
| Professional | | $757.19 | $1,037.25 | $1,037.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.88 / $1,020.92 / $1,603.92
| Professional | | $701.88 | $1,020.92 | $1,603.92 |