- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.07 / $979.06 / $1,091.46
| Professional | | $804.07 | $979.06 | $1,091.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.91 / $3,514.20 / $4,160.39
| Facility | | $2,601.91 | $3,514.20 | $4,160.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.69 / $1,201.99 / $1,664.20
| Professional | | $1,021.69 | $1,201.99 | $1,664.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,064.45
| Facility | | $1,018.60 | $1,018.60 | $1,064.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $743.58
| Professional | | $743.58 | $743.58 | $743.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.79 / $1,084.33 / $1,530.17
| Professional | | $829.79 | $1,084.33 | $1,530.17 |