- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.41 / $1,105.50 / $1,268.40
| Professional | | $934.41 | $1,105.50 | $1,268.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,023.67 / $4,083.84 / $4,834.78
| Facility | | $3,023.67 | $4,083.84 | $4,834.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.32 / $1,396.85 / $1,933.95
| Professional | | $1,187.32 | $1,396.85 | $1,933.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.01 / $1,408.48 / $1,408.48
| Facility | | $1,237.01 | $1,408.48 | $1,408.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,408.48 / $1,408.48
| Professional | | $1,028.19 | $1,408.48 | $1,408.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.31 / $1,221.32 / $1,778.19
| Professional | | $964.31 | $1,221.32 | $1,778.19 |