- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.13 / $1,082.04 / $1,203.96
| Professional | | $797.13 | $1,082.04 | $1,203.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,579.42 / $3,483.86 / $4,124.47
| Facility | | $2,579.42 | $3,483.86 | $4,124.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.95 / $958.77 / $1,603.47
| Professional | | $814.95 | $958.77 | $1,603.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.32 / $1,573.58 / $1,573.58
| Facility | | $1,054.32 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.71 / $1,573.58 / $1,573.58
| Professional | | $1,148.71 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.62 / $1,162.90 / $1,516.95
| Professional | | $822.62 | $1,162.90 | $1,516.95 |