- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.46 / $1,245.10 / $1,481.58
| Professional | | $1,091.46 | $1,245.10 | $1,481.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,531.88 / $4,770.25 / $5,647.42
| Facility | | $3,531.88 | $4,770.25 | $5,647.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.58 / $1,406.57 / $2,259.00
| Professional | | $1,195.58 | $1,406.57 | $2,259.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.39 / $1,295.39 / $1,444.92
| Facility | | $1,295.39 | $1,295.39 | $1,444.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.63 / $1,295.39 / $1,295.39
| Professional | | $945.63 | $1,295.39 | $1,295.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.80 / $1,426.60 / $2,077.08
| Professional | | $975.80 | $1,426.60 | $2,077.08 |