- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.75 / $1,160.94 / $1,252.56
| Professional | | $922.75 | $1,160.94 | $1,252.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,985.93 / $4,032.90 / $4,774.47
| Facility | | $2,985.93 | $4,032.90 | $4,774.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.14 / $1,189.14 / $1,909.82
| Professional | | $1,189.14 | $1,189.14 | $1,909.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,220.48
| Facility | | $1,207.83 | $1,207.83 | $1,220.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $1,207.83
| Professional | | $881.72 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.33 / $1,285.78 / $1,756.01
| Professional | | $964.33 | $1,285.78 | $1,756.01 |